acase@tulane.edu / This dissertation uses a mixed methods design to analyze how the Colombian student-centered school model Escuela Nueva affects learning outcomes, and how well the model is implemented. Primary data from 78 schools in the department Quindío show large variation in implementation across schools, both overall and with regard to the model elements. On average, schools implement only around 62% of the elements. While schools that are officially classified as Escuela Nueva tend to implement more elements than conventional schools, the difference is not large, and considerable variation exists within each group. Qualitative data confirms these heterogeneities, and suggests that differences across schools are even larger than captured by the quantitative data, given the different ways in which the program is being used or adapted in practice. Learning outcomes are measured as scores on the national standardized test Pruebas SABER. Multilevel modeling techniques are used to analyze the scores from over 810,000 students in 21,235 schools across Colombia. The results show that students in schools that are officially classified as Escuela Nueva score significantly better, the difference amounting to 10.5 to 23.2 points (0.14 to 0.30 standard deviations). This effect is comparable to the effect of the difference of one socioeconomic level. Furthermore, Escuela Nueva tends to decrease the achievement gaps between socioeconomic levels and genders. The analysis also reveals large differences in the effect of the school model across municipalities and departments. For the department Quindío, the effect of the school model is analyzed using an implementation index instead of the official classifier. Data is available for 1,068 students in 76 schools, representing half of the department’s rural primary schools. Multilevel estimation generally shows no effect of program implementation, but cannot take into account the large relative sample size. Survey estimation techniques reveal a large effect of Escuela Nueva implementation for grade 3 mathematics and for civic competencies, where the difference in the expected score between a school with a low and one with a high implementation index is 140 to 220 points. The department-level analysis also confirms that the Escuela Nueva model helps to close gaps between socioeconomic levels. / 1 / Katharina Hammler

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This study aimed to create a holistic understanding of the physician experience in relation to telemedicine. This study examined a Tele-NICU and a Tele-ER program at a large metropolitan pediatric specialty hospital with a Level IV NICU that provides telemedicine consults to 16 remote sites across Texas. Twenty-four semi-structured interviews were conducted with physicians and nurses at remote hospitals, physicians who provide consultations from the pediatric specialty hospital, and managers of the tele-specialty programs. These interviews were coded using the consolidated framework for implementation science to contextualize program strengths and weaknesses and reviewed to make recommendations for future program development. Remote site participants reported that the programs are useful when they are in need a second opinion and providing reassurance to patient's families. Barriers to program use include issues with the tele-carts, insurance acceptance, and hesitation to request a consult. Study findings demonstrate the need to treat each tele-specialty programs as independent to suit the differing needs of both remote sites and the consulting physicians. This study demonstrates the importance of understanding physician's perspectives, culture, and the role of hospital settings in telemedicine program acceptance and refutes telemedicine as a monolithic solution to limited healthcare access.

Evidence-based practice (EBP) in children’s mental health has the potential to treat childhood psychological concerns in a more effective and cost-efficient way. Despite the American Psychological Association’s commitment to EBP utilization, current efforts to disseminate and implement EBP into routine care have been slow. This slow uptake may adversely affect children and families by limiting their access to effective care. These consequences may be exacerbated in rural communities due to lack of qualified professionals and resources necessary to implement EBP. Previous research has identified several individual clinician factors and mental health agency characteristics that may influence the success of implementation efforts. These factors include clinician demographic variables (e.g., education level, theoretical orientation, discipline, years of clinical experience, caseload size), clinician attitudes toward EBP, clinician knowledge of EBP, agency characteristics (e.g., setting, size, supervision method, available funding), organizational culture, and organizational climate. The current study investigated how these variables are associated and affect EBP implementation in rural areas. Fifty-five rural mental health providers who provide therapy services to children completed questionnaires assessing current use of EBP, attitudes toward and knowledge of EBP, and agency culture and implementation climate. Results indicated that rural clinicians possessed relatively positive attitudes toward EBP, perceived their organization’s culture and climate as conducive to EBP use, and were just as knowledgeable about EBP as clinicians from urban and mixed rural-urban samples. However, clinician knowledge of evidence-based therapy techniques was not related to EBP utilization. Results also indicated that organizational culture was negatively associated with EBP use and suggests that further research is needed to clarify how clinician and agency variables affect EBP utilization in rural areas. These findings have important implications for EBP training programs. Specifically, extended supervision and consultation models should be incorporated into continuing education workshops and content related to organizational factors (e.g., strategies for fostering an organizational culture and climate conductive to EBP use) should be included. Findings from this study also highlight the need for more effectiveness research to be conducted in rural settings to address the unique barriers experienced by rural clinicians.

Implementation science is a relatively new field focused on ensuring that programs are planned well and then delivered as planned. This thesis describes the implementation process for a nursery-level charity school in Kigali, Rwanda, focusing on the facilitators and difficulties encountered in establishing this school. The research process consisted of interviewing 13 individuals that are a part of the school in question. The researcher transcribed the interviews using an implementation science framework and found trends in their statements that shed light on the establishment of the school. With the help of three coders, the researcher assessed their comments for evidence of helps and hindrances through the implementation process. This thesis presents the results and the implications for implementation science. It will provide valuable information for those wishing to start and maintain grassroots, charitable programs for children in the developing world.

Evidence-based medicine calls for the use of current best evidence (together with individual clinical expertise). Guidelines aim to distil such evidence, yet clinical practice often fails to follow guidelines, for multiple reasons that are still not well understood. One under-researched aspect of the gap between guidelines and practice is psychology. My literature review found that the application of psychology to implementation research has been limited, and such research is not well integrated into wider implementation research. In this study, I sought to a) systematically apply psychological theory to understand the different psychological processes in the stages of adoption described in the diffusion of innovations model; b) collect and analyse data to explore and test this new, psychologically-enhanced model of guideline adoption; and c) improve and extend my model in the light of my empirical data. Having populated my proposed framework with potentially relevant psychological theories based on my literature review, I undertook a first assessment of the validity and added value of this proposed theoretical framework through a case study of the implementation of guidance on universal offering of HIV testing in hospitals serving populations meeting the criteria for high HIV prevalence in the catchment population, interviewing 20 healthcare professionals across two sites. My findings broadly supported my proposed theoretical approach, and illustrated relevant psychological theories for different stages of adoption. My findings support two provisional conclusions. First, that there is potential to improve the effectiveness of efforts to implement guidelines by augmenting the widely-used innovation adoption model with specific psychological theories. Second, that policymakers would do well to shift from viewing the health system as a complicated entity that policy can control and direct is misconceived; I recommend shifting to a perspective of the health system as a complex system, and rethinking the role of policy from that perspective.

BACKGROUND: The VA is the nation’s largest hepatitis C virus treatment provider with a large cadre of HCV specialty care providers. Nevertheless, when highly effective, but expensive all-oral interferon-free medications (directly-acting antivirals, DAAs) for HCV were released, the unanticipated high demand created a VA pharmacy funding shortfall. As this shortfall became apparent, the Veterans Choice Program’s “Choice First” (Choice) initiative emerged. Through Choice, veterans could seek HCV care from non-VA community providers in lieu of waiting for VA care, which in turn complicated access and adoption of DAAs. This study examined VA patient and providers’ experience of and reactions to new DAAs and the implementation of Choice for HCV care.

 METHODS: A qualitative study informed by grounded theory methodology was conducted involving semi-structured interviews with 38 veteran patients and 10 of their HCV providers at three VA medical centers in New England. Patient and provider interviews focused on their experiences with the new HCV treatment, and the processes of care in the VA and through Choice.

 RESULTS: Five themes emerged: 1) the VA’s implementation was considerably more reactive than planned, 2) adopting highly effective HCV medication and Choice were both symbiotic and reciprocally confounding, 3) patient demand and provider awareness were attributed to direct-to-consumer-advertising, 4) the VA organizational structure was not perceived as conducive to rapid implementation of highly effective, demanded, yet costly medication, and 5) veterans and providers had similar perceptions of treatment candidacy. 

 CONCLUSIONS: The VA initially achieved a rapid pace of treating veterans with the DAAs, but eventually could not keep up with demand, leading to a largely unsuccessful attempt to refer patients to non-VA care for HCV treatment. The VA acted as a complex adaptive system and responded to implementation difficulties by applying new policies, which were often opaque, disrupted provider heuristics and practices, and impaired patient autonomy. Patients and providers embraced the HCV treatment innovation, but their experiences navigating community HCV care through Choice indicated a number of flaws in the execution of that program. Choice could have been implemented more effectively with proper recognition and measurement of system antecedents. / 2026-10-31T00:00:00Z

Multi-Tiered System of Supports (MTSS) is a model that can be implemented in school buildings with the support of school district leaders. However, the voices of district leaders involved in MTSS implementation are limited in the research. This study sought to investigate what district leaders perceived as impacting factors towards MTSS implementation and draw conclusions about impacting factors from their opinions. Ten district leaders in a mountain west state of the United States were interviewed via Zoom and had their transcripts analyzed for impacting factors using a form of thematic analysis. All participants were involved with MTSS at their district in some form. This study identified four themes from the data: Personnel Involvement, Pervasive Influences, Foundations and Framework, and Supports Beyond the Site Level. Within each theme, multiple constructs came across which may be beneficial to those looking to implement MTSS or would like to better sustain MTSS implementation in their schools. Findings of this research study can directly impact districts and schools in their planning stages of MTSS implementation that could lead to longer and stronger sustainment of MTSS in their schools. Some examples of ideas drawn from the data include how school systems may want to consider the personnel they currently have access to or could potentially gain access to; they may want to consider emphasizing data and dedicate time to work on MTSS implementation; they may want to consider creating a strong structural foundation so that future implementation will be better sustained, such as structuring practices in a way that they can continue despite changes in personnel; they may want to consider which outside supports they have available to them to assist in supporting implementation.

This presentation will feature real world implementation examples from a seasoned interprofessional team working in a high needs primary care clinic. In Part 1 of our session (approx. 30 minutes), we will define implementation science and familiarize the audience with the EPIS framework (Aarons, Hurlburt, & Horwitz, 2011). We will also describe champion teams as a practical and efficient way to conduct implementation science on the clinic level. Part 2 of our session (approx. 30 min) will be dedicated to translating concepts learned in Part 1 to audience members' personal work via individual worksheets, small and large group discussion, and a question and answer period. Additionally, participants will gain access to an electronic toolkit with relevant articles, worksheets and materials to and build on ideas generated during the session and support their project implementation after the conference.

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