As evidence-based programs are implemented in real world settings, there is a strong need to effectively and efficiently monitor fidelity, or adherence to a program, in order to maintain the expected effects demonstrated in research settings. The purpose of this study was to compare two methods of assessing fidelity to an evidence-based, parent-training model (SafeCare®) as implemented by community service providers. Specifically, analyses compared fidelity assessed via video versus audio recordings. SafeCare modules often require mobility and high interaction, thus, video recordings may provide a more accurate view of home visitor and family interactions for scoring fidelity. However, videos are more expensive and cumbersome in comparison to audio recordings. Trained coders were randomly assigned to score a video or audio recording of the same session for 25 SafeCare sessions and the codes were compared for agreement. Two types of SafeCare sessions were assessed: assessment and training. Average agreement was somewhat higher for assessment sessions than for training sessions. Average agreement, across all sessions, was higher among items pertaining to SafeCare content than items pertaining to the therapeutic process. Several specific items were identified that are difficult to code via audio recordings. However, more research is needed to determine agreement levels across all SafeCare modules and session types in order to provide insight on the implications for SafeCare's future use of audio and video methods of measuring fidelity.

Neglected Tropical Diseases (NTDs) are both causes and manifestations of poverty in developing countries. Recent advocacy efforts have increased the profile of NTDs, and led to bold new control and elimination targets set for 2020 by the World Health Organisation. However there are multifaceted challenges in effectively implementing NTD interventions in resource-poor contexts that need to be understood and engaged. While there is a growing call by researchers and international agencies for a science of global health delivery to understand these complexities, the exact nature of this science remains contested. This thesis contributes to these debates by advancing a critical social science perspective on the factors that mediate intervention effectiveness for NTD control. Grounded in a social constructivist approach using mixed methods, it critiques prevailing orthodoxies by unpacking the nature, processes and outcomes of three large-scale NTD prevention programmes in Eastern Africa. Focused on different diseases, these case studies represent different types of intervention approaches: top-down, participatory and public-private partnership. The thesis traces the social, technical and environmental processes that mediate the delivery, adoption and use of particular health technologies, such as pit latrines, insecticides and vaccination. Together, these case studies reveal surprisingly similar reasons for why many interventions do not perform according to expectations. Despite new approaches that claim to overcome stereotypical challenges of top-down planning, narrow technocratic perspectives continue to play a defining role in maintaining disjunctions between global aspirations, local realities and intervention outcomes. New perspectives and changes in orientation are needed that emphasise flexibility, learning and adaptability to local contexts. Towards this end, the thesis outlines a conceptual framework based on a comparative analysis of the case studies that highlights five interrelated domains where effectiveness is determined: geographical/livelihood variation, local agency, incentives, the socio-materiality of technology and planning/governance. I argue that addressing the shortcomings of contemporary interventions requires that programme planners actively engage these domains by seeking to “order complexity.” Greater integration of social science perspectives into the management of NTD programmes would provide significant benefit. In these ways, the thesis contributes to wider debates about the nature of global health interventions and the influence of local contexts in mediating efforts to improve the health and wellbeing of the world’s poor and marginalised.

The 2015 refugee crisis clearly highlighted that the European asylum system is flawed and triggered a heated discussion on the functioning and appropriateness of the Dublin Regulation. The present research tries to account for differences in the implementation of the Dublin regime from its coming into force in 1997 until today, by testing the three possibly influencing factors 'misfit', administrative capacity and overall situation for Germany, Hungary and Italy. The comparative case study first ascertains that Germany implements the obligations to a medium to high degree, while Hungary presents a low and Italy a medium-low implementation record. The analysis of the single variables shows that the higher the compatibility between the national and the European asylum system at the moment of adhering to the Dublin system, the more diligently a country implements it. While no clear claims can be made if and how the administrative capacity of a state affects implementation, the economic situation does have an impact in the sense that a stronger overall state of the economy appears to have positive effects on implementation. The research is part of the general research framework of Europeanization and contributes to the scholarship on implementation. By shedding light on the factors leading to...

As more evidence-based programs are implemented in community settings, there is a strong need to ensure those models are implemented with integrity. Implementation of programs should be evaluated for fidelity, the degree of adherence to treatment protocols, and competence, the level of skill in implementation (Schoenwald et al., 2011). The purpose of this study was to review audio recordings of SafeCare home visiting sessions to discover the relationship between the measures of fidelity and competence. Six coders were assigned 209 SafeCare home visiting audiotapes to be coded for fidelity and competence. A sample of audios were double coded to evaluate fidelity and competence scores for inter-rater reliability. Fidelity and competence items were classified into process and content categories, forming the six main variables of process fidelity, content fidelity, total fidelity, process competence, content competence, and total competence. Total fidelity correlated with total competence at a level of .615, with process fidelity and process competence correlating at a much lower level than content items. The total correlation level can be interpreted as that fidelity and competence are strongly related measures, but are not identical constructs. The goal for SafeCare coders would be to continue refining competence definitions and attempting to remove the subjective nature from the competence coding process. With these two efforts, competence reliability should increase to an acceptable level. Given the main fidelity and competence correlation level, it is advisable for SafeCare coders to continue to code both fidelity and competence to avoid missing valuable components of the session. Additional research may be needed once the competence scale becomes better established.

In 2012, federal legislation introduced a requirement for formal transportation asset management (TAM) in transportation agencies. The law specifically requires agencies to develop TAM plans and implement TAM programs in their decision-making processes. The history of national policy development for (TAM) and research in policy implementation and organizational theory have shown that program sustainment is not easily achieved. Often, agencies can respond to this kind of legislative mandate with ineffective efforts to achieve legitimacy that reduce the likelihood for the program to be sustained in the long-term. This presents a challenge because without sustainment, the benefits of TAM, which are mostly long-term, may not be fully realized. The objective of this work was to develop a conceptual framework to guide transportation agencies to review their TAM implementation practices and identify opportunities to enhance long-term program sustainment. The conceptual basis for the framework comes from a synthesis of transportation, policy and program implementation, and change management literature, supported by insight from a panel of practitioner and academic experts. The TAM Implementation Review Framework (TIRF) incorporates seven themes of implementation factors that can promote sustainment of TAM practices impacting the social, organizational, and programmatic elements of implementation. The TIRF was applied in case studies to review the TAM implementation processes of three Departments of Transportation (DOTs) resulting in different kinds of information on how implementation activities address factors related to program sustainment. These results can steer future implementation activities in DOTs towards increased probabilities of achieving long-term program sustainment. The primary contributions of this work lie in the development of the conceptual framework and approach to enhance TAM implementation by emphasizing the people and organizational elements of TAM, alongside with the technical. In practice, the TIRF offers agencies a review and planning tool to support TAM implementation decision making and to promote program sustainment. The output is being proposed as a foundational element in the development of an evidence-based catalog of TAM implementation strategies. This can facilitate inter-agency knowledge sharing by providing a platform for systematic documentation of implementation experiences to support broader adoption of strategies that can contribute to increased program sustainment.

Study Purpose: Ovarian cancer, the most lethal gynecologic cancer, has had a relatively stable mortality rate since 1975, despite a decrease in mortality for all gynecologic cancers combined. Standard-of-care advances are needed to reduce ovarian cancer morbidity and mortality. Advances must, however, undergo a long, rigorously controlled research process that can take more than ten years before becoming available to the public. Further, few women with persistent or recurrent ovarian cancer are offered or enrolled in the clinical trials that do exist at select sites throughout the nation. The purpose of this multiple-case study is to identify necessary and/or sufficient factors associated with enrollment in ovarian cancer clinical trials, and to identify facilitators and barriers within the practice setting that, in the longer term, can be used to inform targeted interventions to improve trial access and accrual. The multilevel factors that were explored were aligned with the Consolidated Framework for Intervention Research (CFIR). The study sought to answer two research questions. (1) Based on Qualitative Comparative Analysis [QCA (Ragin, 1989)], what necessary and/or sufficient factors would enable a woman with recurrent or persistent ovarian cancer to enroll in a clinical trial in Florida? (2) What barriers and facilitators, practitioner and patient-specific, exist with regard to enrolling women with ovarian cancer in clinical trials? Materials and Methods: This multiple case study used online surveys to obtain quantitative and qualitative data from two populations: women with ovarian cancer and nurses at various referring practice sites. Data from Moffitt Cancer Center’s Total Cancer Care protocol was requested to conduct chart reviews that would identify prospective participants. Qualitative comparative analysis (QCA), which is useful for determining causality in small sample sizes, was used to determine necessary and/or sufficient factors associated with enrollment by women with ovarian cancer in clinical trials, as well as barriers and facilitators related to clinical trial enrollment. Results: Women with ovarian cancer who participated in clinical trials were stage III/IV, wanted information, and engaged in discussion about clinical trials, making those factors necessary for enrollment in a study. Facilitators for participation were discussion with the provider of care, to some extent the existence of patient-accessible clinical trial literature in the practice, knowledge that health insurance covers standard of care costs, and having a provider who offers clinical trials. Absence of those factors thus constitutes a barrier. For nurses, the impact of having a practice team plan was related to enrolling women with ovarian cancer in clinical trials, and feeling informed and comfortable with questions women might ask about trials. Conclusion: Clinical trials are an underutilized priority for improving the standard of care and reducing the high rate of morbidity and mortality associated with ovarian cancer. The data show deficits and needs within two key interrelated populations: medical oncology practice nurses and women with ovarian cancer. Opportunities exist within each level of the Consolidated Framework for Implementation Research (CFIR); interviews should be used to confirm the findings, which can be used to establish an interventional protocol to increase clinical trial enrollment by women with ovarian cancer.

Background/Purpose: Reducing the incidence and negative consequences of concussion among youth athletes is a public health priority. Fifty states have adopted legislation addressing the problem of sports-related concussions among youth-athletes. In 2010, Massachusetts adopted legislation based on Washington State’s Lystedt Law, enacting state-wide requirements for high school athletic programs. This study explored how the legislation has been implemented within Massachusetts schools and school-districts and identified factors influential to local implementation. Methods: A qualitative multiple-case study approach was utilized. US Census data concerning the household median income and population size of the school-district’s representative town(s) were used to purposively recruit cases. Semi-structured interviews with a breadth of school-district actors in the Commonwealth of Massachusetts and archival records associated with participating schools were used for analysis. Interview data were analyzed using a conventional content analysis approach. Written documents were subjected to an archival analysis. Results: 19 participants from 5 schools were interviewed. Interviewed school personnel included 5 athletic directors, 5 coaches, 4 athletic trainers, 4 school nurses, and 1 health and wellness coordinator. Eight case-level themes related to how the regulation was implemented were identified, and 6 influential factors related to the regulation’s implementation emerged. All participating cases decided to utilize neurocognitive baseline testing programs to assist in diagnosing concussions. Cases also decided to place the decision making authority of removal-from-play and return-to-play situations in the hands of athletic trainers. Primary care physicians were expected to provide medical clearance for concussed student athletes. Funding and man-power emerged as a threat to schools’ ability to implement the regulation with high fidelity. Conclusions: At the local level, provisions of the Massachusetts regulation were implemented with high fidelity. However, differences and similarities regarding local-level implementation decisions existed across cases. Conducting the study qualitatively allowed the study to obtain rich detail and identify implementation decisions made within cases. However, the knowledge generated may not be generalizable to other school districts or other states. The study’s findings speak to the variability often found when implementation is relegated to the local-level.

Introduction: Non-invasive ventilation (NIV) is an alternative method for providing safe mechanical ventilatory assistance to adult patients presenting with acute respiratory failure. Internationally the utilisation of NIV has increased by 400% during the past decade. The clinical pathway for NIV was collaboratively developed by the multidisciplinary team in the critical care unit in 2012, but implementation into practice did not realise as anticipated. As the burden of chronic disease rises in South Africa, the healthcare system is under pressure to provide evidence-based and costeffective care to more patients. Avoiding endotracheal intubation reduces the patient’s risk of complications which lengthens the hospitalisation period and the cost of hospitalisation. The utilisation of clinical pathways in the South African context is limited. Aim: The overall aim of the study was implementation and evaluation of the outcomes of a person-centred clinical pathway for non-invasive ventilation in the critical care unit. Research methodology: Mixed method design through a personcentred practice development approach utilising emancipatory action research. Several data collection methods are used throughout the phases of the study. A critical realist worldview was held which incorporated the principles of a person-centred approach through collaboration, inclusion and participation. The study was conducted in three interdependent and interrelated phases. During Phase 1, the culture of the critical care units was assessed using a validated 37-item questionnaire to establish the perceptions of the critical care nurses related to evidence implementation. A total of twenty-three registered nurses participated. Additionally, the content of the clinical pathway was adapted following a rigorous literature review in collaboration with the internal facilitators and validated via a Delphi with critical care experts. Phase 2 was dedicated to the collaborative development of an implementation strategy for the implementation of the clinical pathway in the critical care unit. During Phase 3, the outcomes of the implementation of the clinical pathway for NIV was evaluated. Findings: The collaborative utilisation of a person-centred practice development approach for the implementation and evaluation of the clinical pathway for NIV, aided the researcher in identifying moral injury amongst critical care nurses, which inhibits the implementation of research evidence into practice. / Thesis (PhD)--University of Pretoria, 2020. / Nursing Science / PhD / Unrestricted

Dissemination and Implementation (D&I) Science is an evolving field of models and methods aimed at closing the research-practice gap. This chapter provides an overview of D&I Science with particular emphasis on its relevance for academic and clinical medical family therapists (MedFTs) and/or graduate students in training. It begins with a discussion of the poor reach of evidence-based treatments, building a case for the evolution of D&I Science. Basic definitions of dissemination research and implementation research are provided, followed by a description of the characteristics of D&I Science. Two exemplary D&I models are described with examples that relate to MedFT. The chapter closes with a discussion about how the reader can learn more about this dynamic and growing field.

BACKGROUND: Individuals with serious mental illness face a significant burden of disease, yet experience lower quality care across a range of services (1). Hospital readmission within 30 days of discharge is an important, if imperfect, proxy for quality of care. Factors contributing to readmission are well documented (2–5), yet successful interventions to decrease readmissions have been slow to take shape (6–9). To effectively develop and incorporate evidence-based interventions to reduce 30-day psychiatric readmissions into large, geographically diverse inpatient systems; there is a need to conduct in-depth implementation analyses to better understand the relationship between patient-, hospital-, health system-, and community-level factors and their net impact on readmissions. This research addresses this need. METHODS: Using a modified Consolidated Framework for Implementation Research (CFIR), two state-based case studies were conducted within a large U.S. hospital system. Two hospitals per state were selected-- one with a high and one with a lower readmission rate. We conducted document reviews and semi-structured interviews (N=52) with corporate, clinical and community stakeholders, using the CFIR to identify key themes within each construct. We scored and compared hospitals with lower vs. higher readmission rates. An analysis of EMR data from the hospital system contextualized case study findings. RESULTS: In one state a complex interplay of factors at all levels contributed to readmission rates in both hospitals. In the second, constructs within the inner hospital setting contribute to differences in hospital readmission rates. Facilities with high readmission rates scored lowest among CFIR constructs “Patient Needs and Resources in the Community” and “External Policies and Incentives.” CONCLUSIONS: Ours is the first known study to explore a broad range of factors that influence readmission rates among patients with serious mental illness and a range of comorbidities. Findings from two state-based case studies indicate that readmission rates are determined by multiple, interrelated factors which vary in importance based on hospital and community context and political environment. To be effective, systemic interventions to reduce readmissions must be tailored to the specific context at targeted hospitals.