As the management of dementia is a significant public health concern, efforts to increase access to effective treatments to a greater number of residents with dementia in skilled nursing facilities (SNFs) are warranted. The treatment addressed in this study, non-electronic external memory aids, is an evidence-based practice that has been found to increase positive communicative interactions and decrease negative behavioral problems of residents with dementia in SNFs. Although use of memory aids is recommended, there are significant barriers such as lack of time and resources that inhibit the use of effective treatments in typical clinical settings. To address such barriers to evidence-based practice (EBP) implementation, the Promoting Action on Research in Health Services (PARIHS) framework is available. The PARIHS framework accounts for elements outside of the clinician knowledge base that may impact EBP delivery such as perceptions of the specific EBP and the specific context in which the EBP will be delivered. Organizational variables such as culture, leadership priorities, and resource availability are considered. Although the PARIHS framework has been used to successfully study and support EBP uptake in other areas of health care such as nursing, this framework has not to date been used in the field of Speech-Language Pathology, the clinician group of interest in this study. This study utilized a transformative, mixed-methods design within the PARIHS framework to investigate potential impacts of Speech-Language Pathologists' (SLPs) and Facility Rehabilitation Directors' (FRDs) perceptions of the evidence and organizational context on the use of non-electronic external memory aids in SNFs. The project explored differences between FRDs' and SLPs' perceptions of such variables, as well as the relationship between those variables and the SLPs' reported percentage of use of non-electronic external memory aids. Qualitative methods through semi-structured interviewing of SLPs further provided contextualized and detailed data regarding facilitators and barriers to the use of memory aids in SNFs. Results of the study indicated that there were statistically significant differences between SLP and FRD groups in terms of perceptions of the organizational context in the SNF, with the FRDs viewing the organizational context more favorably. There were no significant quantitative differences between SLPs and FRDs in terms of perception of the evidence for the practice of non-electronic external memory aids. Both groups demonstrated relatively favorable perceptions of the practice (3.8 on a 5-point scale with 5 being strongly favorable). Each additional point regarding favorable perceptions of SLPs in terms of the evidence for non-electronic external memory aids were associated with a 24% increase in percentage of use of the practice. Perceptions of the organizational context in the SNF were not significantly associated with higher percentages of SLP use of the practice; however, issues of organizational context were heavily present in the qualitative data. Analysis of the interview data yielded a total of 318 codes and 191/318 (60%) of those codes addressed issues of organizational context. Qualitatively, the most common codes related to issues of lack of necessary staff to both implement and sustain the use of non-electronic external memory aids. Further, lack of physical materials and time to create memory aids was also a frequently reported barrier in the interview data. There was not mention of local performance data or systems for which to evaluate performance in relationship to non-electronic external memory aid usage in the interview data. Results of this study may contribute to the acceleration of a successful, systematic uptake of non-electronic external memory aids for residents with dementia in SNFs by considering SLPs' perceptions of evidence and by engaging the end organizational context. This project may also serve as a model to contribute to the successful implementation of other EBP for patients with cognitive-communicative impairments.

Since 1995, a thrombolytic therapy, rt-PA, has been approved for use with acute stroke that significantly reduces, and sometimes reverses, neurological damage. Treatment has to be given within a few hours of the start of symptoms and can only commence once a CT-scan has confirmed a particular type of stroke. In the evidence-based medicine and knowledge translation literature, variations in practice are constituted as a problem to be solved. It is assumed that a physician decides whether or not to use this therapy based on his/her evaluation of the scientific evidence. In this thesis, I demonstrate that what are less evident in many of these claims are issues related to the social production of knowledge. Little attention is paid to who conducts research, who promotes its findings, and who is expected to implement them. The positivist discourse of evidence-based medicine assumes that research produces knowledge that is neutral and can be translated into treatment that is in the patient’s best interest. Yet these assumptions remain empirically unexamined, despite social science critiques of these processes. Institutional Ethnography is an approach in sociology developed by Dorothy Smith. Based on Smith’s understanding of the social organization of knowledge, it allows for an examination of the complex social relations organizing people’s experiences of their everyday working lives. Beginning in the experiences of physicians who provide acute stroke services, this dissertation explores an example of how best practice medicine is developed, translated, and taken up in practice across various sites in the province of Ontario. For Smith, texts mediate and organize people’s experiences. In my study, the discourses of both evidence-based medicine and knowledge translation, designed to improve patient care, come into view as managerial tools designed to control the delivery of care. I render visible how in fact things work as they do in real life settings in a way that links back actual people to the texts, or discourse, organizing their experiences. In so doing, I am able to uncover some of the assumptions and hidden priorities underlying the current emphasis on translating scientific knowledge in medicine into practice.

Obesity, a condition of excess body fat, is one of the most complex problems facing health systems. Lifestyle management programs that combine diet, physical activity, and intensive behavioral therapy have been shown by research to support a degree of weight loss that produces health benefits (i.e., at least a 3-5% initial body weight). However, it has been difficult for research-developed programs to be delivered in typical practice to have a meaningful impact. Integrated research-practice partnerships that involve the coming together of academic researchers, health system administrators, and program delivery staff may help overcome this gap, especially during this transformational time in the healthcare sector. This dissertation aimed to develop an understanding of how using the integrated research-practice approach would facilitate and sustain evidence-based lifestyle management strategies across a health system to treat obesity among patients and employees. An integrated research-practice partnership with Carilion Clinic, a health system in western Virginia, served as an example for the study. From 2013-2016, the Carilion Clinic integrated research-practice partnership conducted a series of trials testing different strategies for delivering weight loss and weight loss maintenance support. An evaluation guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework was conducted to describe implementation processes and outcomes for each strategy. Lessons learned from the evaluation support the value of the integrated-research practice partnership approach as a solution for overcoming gaps in obesity care. A shared priority perspective between research and practice was identified as the powerful process for supporting facilitation and sustainability of strategies. In addition, findings from the evaluation produced evidence to inform the future development of a system for Carilion Clinic to help patients and employees lose weight and keep it off through lifestyle management. / Ph. D.

Abstrakt Bakgrund: Under lång tid har apoteksbranschen och den farmaceutiska professionen önskat utveckla farmaceutiska tjänster på öppenvårdsapotek samt få offentlig finansiering för dessa. Nya metoder som ska införas i en verksamhet tar ofta lång tid, kostar mycket och misslyckas ofta. Den process som används för att införa nya metoder i en verksamhet kallas implementering. Forskning visar att kunskap om implementering kan påverka resultatet framgångsrikt och att processen tar två till fyra år utan sådan kunskap genomförs implementeringen efter i genomsnitt 17 år. Syfte: Syftet är att identifiera vilka faktorer som kan påverka implementering av farmaceutiska tjänster på öppenvårdsapotek och belysa hur dessa faktorer påverkar implementeringen Metod: Arbetet har baserats på en litteraturstudie med hjälp av SBU:s handbok. SBU:s handbok handlar om utvärdering av metoder i hälso- och sjukvården och insatser i socialtjänsten. Artikel sökningen gjordes mellan 2020-04-08 till 2020-04-15. Totalt inkluderades 30 artiklar via databas PubMed och involverade följande termer: Cognitive service, community pharmacy, implementation science, barriers and facilitators.        Resultat: Implementering av farmaceutiska tjänster på öppenvårdsapotek är en komplex process och det finns olika faktorer som påverkar implementeringsprocessen och resultatet. De centrala begreppen för implementering är bl.a. process-modell, innovation, sammanhängande domäner av faktorer, strategier och utvärdering. Process-modellen består av fem olika delar, bland annat utforskning, förberedelse eller installation, testning och initial implementering, full verksamhet och hållbarhet. Ett vanligt ramverk som används i olika studier kallas det konsoliderade (förstärkta) ramverket för implementeringsforskning (CFIR). CFIR används för bedömning av olika faktorer som påverkar implementeringen. Faktorerna som påverkar implementeringen delas in i två grupper, hindrande (barriärer) och underlättande (faciliterande) faktorer. Slutsats: Implementering av farmaceutiska tjänster på öppenvårdsapotek påverkas av olika hindrande och underlättande faktorer. För att få en framgångsrik implementering behövs en processmodell och ett ramverk. Det behövs mer forskning för att utveckla processmodellerna och ramverket för få bättre resultat av implementering av farmaceutiska tjänster på öppenvårds apotek.

INTRODUCTION: Performance–Based Grant Agreements are increasingly being used in Nepal in the healthcare sector, especially at public-private partnership hospitals. As interest in these agreements grows, it is essential to understand the process of implementation so that Nepali healthcare policy–makers can make better informed decisions about how they impact the public health situation of Nepal. This project studied the process of implementing Performance–Based Grant Agreements using qualitative research methods to interview key informants about their opinions, perceptions, and experiences associated with these agreements. METHODS: Semi–structured interviews with open–ended questions were conducted with key informants who have direct knowledge and experience about the design, implementation, and impact of the Performance–Based Grant Agreements. The key informants included healthcare administrators and healthcare workers at the various implementing hospitals, Government of Nepal officials, and members of various External Development Partners; these participants were chosen using a combination of purposive and convenience sampling methods in an attempt to triangulate responses and to generate a diversity of opinions, and perspectives. Participants were asked about their experiences with the Performance–Based Grant Agreements and interviews focused on associated challenges, opportunities, learned experiences, and both expected and unexpected consequences. Data analysis was overlapping with data collection and concentrated on identifying recurrent themes and ideas from transcribed interviews. These themes and ideas along with illustrative quotes guided discussion and results. RESULTS: A total of 16 interviews, ranging from 12 minutes to 75 minutes in length, were conducted with different hospital administrators, Government of Nepal officials, and members of different External Development Partners about the Performance–Based Grant Agreements. Participants had widely varying experiences about the process of implementing these agreements, which yielded a diversity of responses. DISCUSSION: There was an awareness gradient among the participants about the agreements as some participants had barely heard of the contracts while others had detailed knowledge of how their institution was implementing them. The process of implementation for participants and their institutions included grappling with the concept of conditionally tying funding to performance, figuring out how to do monitoring and evaluation, understanding the barriers to implementation, and using new technology and practices to meet the demands of the agreements. Despite the varying experiences associated with implementation or a lack thereof, participants were unanimous in their support for the adoption of these agreements and hopeful that these agreements can enhance partnership while improving the delivery of health services in Nepal.

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Globally, children and youth are more vulnerable to experiencing mental health challenges; early intervention is key to preventing ongoing mental health difficulties into adolescence and adulthood. School-based mental health interventions have proven to be effective but require a significant amount of collaboration between teachers, parents, mental health specialists and other important stakeholders. Equally noteworthy are the significant treatment, resource and capacity gaps between high and low to middle income countries when it comes to child mental health; the SHINE research group seeks to implement a school-based mental health program in countries in the Eastern Mediterranean region. They also intend to scale-up the prevention and intervention capabilities of said countries to improve overall child mental health. This study investigated the role of collaborative care in SHINE’s program development and implementation processes, while examining the cultural and societal challenges associated with implementing a school mental health program developed primarily in high-income countries to specific non-Western contexts. Individual and small-group indepth interviews were conducted with ten key stakeholders from the SHINE team and partner countries (specifically Iran, Jordan and Egypt). Findings identified the potential for the collaborative care approach within the SHINE school mental health program to greatly ameliorate child mental health outcomes. Additionally, participants noted the necessity for clearer stakeholder role definition and differentiation of general vs specific program elements between countries. Challenges associated with implementing the intervention in the Eastern Mediterranean region included the dominant role of the family, challenging societal norms and stigmatization and structural barriers to applying SHINE’s specific program resources. In summary, the role of collaborative care is increasingly important to SHINE’s current efforts in improving child mental health, however, individual cultural and country characteristics should be an area of emphasis moving forward. / Thesis / Master of Science (MSc) / The SHINE research group are implementing a school-based mental health intervention in the Eastern Mediterranean region, alongside a facilitated collaborative learning group involving key local and global stakeholders. This study focuses on the collaborative care element of the school-based mental health program and its impact on the overall functioning of the intervention, in different country contexts. Collaborative care involves the interactions between parents, teachers, mental health professionals and researchers to ensure the sustainability of the program as well as its scalability to different country contexts. This is an exploratory qualitative study with a case study design; data has been collected with ten participants through individual and small group in-depth interviews. Interviews were transcribed, coded and then cross-compared using thematic analysis to identify overarching patterns. The primary goals of the study are to examine the role of collaboration as well as to consider some of the challenges of applying Western psychological interventions to diverse country and cultural contexts.

This View From the Field column is the third in a series describing the important contributions of the field of implementation science in supporting educators in implementing evidence-based practices (EBPs; Kittelman et al., 2020, 2021). In the previous columns, we highlighted the importance of selecting EBPs and establishing school implementation teams to provide support to students, and support to educators, in implementing EBPs. For this column, we focus on another component of the Active Implementation Frameworks (Metz & Bartley, 2012) by describing the actions and activities needed to move EBPs through different stages of implementation. In doing this, we highlight the important work of researchers and practitioners from the National Technical Assistance Center on the State Implementation and Scaling-Up of Evidence-Based Practices ([SISEP]; https://sisep.fpg.unc.edu) within the National Implementation Research Network (NIRN; https://nirn.fpg.unc.edu).

In this View From the Field column from the implementation science series, highlighting how the field enhances the implementation and scale-up of EBPs in schools and districts (Kittelman et al., 2020), we discuss the importance of implementation teams and their roles in directing support for students and supporting educators to implement EBPs. We focus largely on the work from researchers and technical assistance providers from the National Technical Assistance Center on the State Implementation and Scale-Up of Evidence-Based Practices (https://sisep.fpg.unc.edu) and the National Center on Intensive Intervention (https://intensiveintervention.org).