Conceptual Framework
Research-to-practice models begin with the researchers and research, while community- practice models begin with the world of practice. (Wandersman et al., 2008, p. 173)
Based on the literature reviewed and the aims of this study, the conceptual framework used to explore how implementation and adaptation of evidence-based interventions are applied in community practice settings using lessons learned from the Modelo de Intervención Psicomédica is the Integrated Systems Framework (ISF) for Dissemination and Implementation developed by Wandersman et al. (2008). ISF is one of the few community-centered models identified in the literature that focuses on dissemination and implementation processes, rather than solely on the former. The most commonly cited theoretical framework offered in the literature to explain the journey from research translation to adoption and application at the community level is Rogers’ (1995) Diffusion of Innovations (DI) which features a series of linear steps in which ideas, practices, or products are transferred from the source (research settings) to the user (community). The focus of DI is on the dissemination and adoption of new “innovations” among members of a social system (Rogers, 1995), more so than on the pre- implementation and implementation processes of EBI application or the infrastructure or systems needed to carry out these functions (Wandersman et al., 2008). Several authors (Fixsen et al. 2005; Flaspohler et al., 2008; Guerra & Knox, 2008) maintain that DI provides guidance up to the point of adoption of an innovation but falls short on providing direction on the actual implementation of an innovation with fidelity. They further conclude that although the adoption process
lends itself to supporting implementation and maintenance of an EBI, such support does not substitute for the actual functions and processes implicit in implementation. The ISF model includes the research translation and adoption processes that are defined within DI theory but also focuses on intervention implementation and sustainability at the community level, including the role of adaptation along the research-to-practice continuum (Wandersman et al., 2008).
ISF follows a community-centered model which purports to consider community needs in the context of the resources and capacity (individual, organizational, and community) required to respond to those needs (Flaspohler et al., 2008; Wandersman et al., 2008). ISF is defined by three major dimensions that span the research-to-practice continuum; each differentiated by specific yet interacting functions resulting in the application of evidence-based interventions in community practice settings. Dimensions include: 1) prevention research and synthesis (dimension 1), prevention support systems (dimension, 2) and prevention delivery systems (dimension 3).
Prevention research and synthesis refers to the development, evaluation, synthesis and translation of research and scholarly literature to prepare it for dissemination and implementation (Guerra & Knox, 2008; Lee et al., 2008; Saul et al., 2008a; Wandersman et al., 2008)
Prevention support systems focus on supporting and building the capacity of the “system”; that is practitioners, organizations and communities, to deliver the interventions. This building is done via two mechanisms: 1) innovation-specific support which refers to capacity building specifically related to the adoption, adaptation, implementation of an EBI, and 2) general capacity-building which refers to the provision of technical assistance to enhance the broader organizational infrastructure, skills, and motivation, without emphasis on a particular EBI. (Lee et al., 2008; Saul et al., 2008a Wandersman et al., 2008).
Prevention delivery systems refer to the practice settings in which interventions are implemented with target populations and the actions taken by individuals, organizations and communities to execute these interventions (Lee et al., 2008; Saul et al., 2008a; Wandersman et al., 2008).
The nucleus of the ISF model is on the infrastructure and systems needed to perform the functions necessary for the dissemination and implementation of EBIs. Interaction between all three systems is viewed as critical to the functioning of the model. In the ISF model, “innovations” from prevention synthesis and translation (dimension 1) are made available to communities for implementation (dimension 3) through strong prevention support systems (dimension 2) that focus on capacity building for individuals, organizations, and communities to facilitate the connection from science to practice (Guerra & Knox, 2008).
ISF also explicitly mentions adaptation as a major component of the model that can occur at any time within all three dimensions of the system. Specifically embedded in dimension 2 (Prevention support systems) is what Lee et al. (2008) refer to as “planned adaptation”.
Planned adaptation [as a tool for community practitioners] serves to orient the provider to the intervention and its theoretical underpinnings; it helps providers identify the usefulness of an intervention model for a particular setting; it serves as a framework to orient practitioners to important issues inherent in implementing and adapting EBPs; in addition, it provides some initial direction in developing evaluation strategies. (Lee et al., 2008, p. 291-292)
According to the ISF model Planned Adaptation works best when accompanied by training, technical assistance, and coaching that encompass the functions of the prevention support systems. ISF presents adaptation as an integral part of the research-to-practice continuum and as a non-linear, interactive and dynamic process that considers the perspectives of multiple stakeholders (such as funders, researchers, practitioners, and technical assistance providers) each requiring various levels of support to ensure the relevance, applicability, and success of the intervention in the field. Adaptation in
the context of ISF is viewed as a tool to be used by community practitioners with caution to support the dissemination and implementation of the EBIs recommended for implementation within their respective settings. Figure 3 illustrates the Interactive Systems Framework as conceptualized by Wandersman et al. (2008).
FIGURE 3: The Interactive Systems Framework (ISF) for Dissemination and Implementation
Implementing Prevention – Prevention Delivery System
Supporting the work- Prevention Support System
Distilling the information- Prevention synthesis and translation system
Excerpted from Wandersman et al., (2008) p. 174
In applying the ISF model to this research inquiry, two components of the model are highlighted, 1) the prevention support systems (dimension 2) which speaks to the capacity of health practitioners and implementing organizations; and 2) prevention delivery systems (dimension 3) which includes the activities conducted to execute and deliver EBIs in community practice settings.
Dimension 1- Prevention research and synthesis, although relevant to the research-to-practice process, is not a focal point of this research study. As the focus of this research is on the
Macro-Policy
Funding
Climate
Existing research and theory General Capacity
Use Innovation-Specific Capacity Use
General Capacity
Building Innovation-Specific Capacity Building
implementation phase of the research-to-practice continuum and the adaptations that occur along the continuum especially in the implementation phase, the emphasis on ISF’s prevention support and prevention delivery systems is understandable.
Building on ISF, the influencing factors of culture, content, capacity and community identified in the literature as impacting intervention adoption, implementation and adaptation in community practice settings also influenced the research approach and the development of the research questionnaire. As such, the research inquiry was organized across four major areas -- pre-implementation, implementation, adaptation, and technical assistance—compatible with the tasks, activities and capacities outlined in the prevention support and prevention delivery systems and the implementation stage along the research-to-practice continuum. Combined, these components extracted from various models and knowledge sources manifested into an enhanced conceptual framework grounded in ISF, to address the research question: How are Implementation and Adaptation of Evidence-Based Interventions Applied in Community Practice Settings?
Figure 4 below depicts the PI’s concept of such an enhanced framework for ISF, inclusive of the other contributing factors identified in the literature as impacting the research-to-practice continuum; and presents the four basic stages of the research-to-practice continuum —adoption, pre- implementation, implementation and evaluation/maintenance and the ISF dimension to which each phase best relates. Although there is overlap in the applicability of ISF’s three dimensions to the various stages along the continuum, the focal areas for this research are highlighted in a darker shade to distinguish relevant components of the model. Adaptation is also included as a component of ISF along all three dimensions, as has been explained but not illustrated in the ISF depiction from Wandersman and colleagues (2008) presented earlier in this section. Lastly, the influencing variables impacting all stages along the research-to-practice continuum, including adaptation is incorporated into this enhanced ISF framework. ………...
Figure 4: Enhanced Interactive Systems Framework for Exploring the Implementation and Adaptation of Evidence-Based Interventions in Community Practice Settings.
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∗Dark shaded area indicates this study’s research emphasis Source: Pemberton, 2011 as Adapted from Wandersman et al., 2008
Stages along the Continuum of Research-to-Practice ADOPTION PRE-IMPLEMENTATION IMPLEMENTATION EVOLUTION, EVALUATION and MAINTENANCE
Interactive Systems Framework for Dissemination and
Implementation with Adaptation Dimension 1: Prevention Synthesis and Translation Dimensions 2: Prevention Support Systems Dimension 3: Prevention Delivery Systems Dimensions 2: Preventions Support Systems
Dimension 3: Prevention Delivery Systems
ADAPTATION
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Study Design and Sampling
In public health, qualitative research findings provide insights about “why” individuals and populations engage in specific behaviors, promote understanding of social processes that result in positive health outcomes and facilitate identification of contextual influences, including historical, social, political or cultural factors that influence the success or failure of an intervention, program or policy (Jack, 2006, p. 279).
Study Design
A non experimental, descriptive qualitative research design was most compatible with exploring the primary research question: How are Implementation and Adaptation of Evidence- Based Interventions Applied in Community Practice Settings? According to various literature sources (Bradley, Curry, & Devers, 2007; Creswell, 2003; Jack, 2006), a qualitative research design is best suited for exploring a phenomenon of interest that has never been studied or for which little information exists, for providing a new perspective on an existing situation or issue, for generating or refining theory, or for understanding the contextual factors that influence and determine health, including cultural, social and political influences. Qualitative research is especially valuable when attempting to convey to policy makers, funders, administrators, and other decision makers, the processes and factors that contribute to the success or failure of interventions or policies through the identification of the facilitators, barriers, and contextual issues that impact the program of focus (Jack, 2006).
The selected research design is also compatible with the conceptual model developed to guide this research. The Enhanced Interactive Systems Framework for Exploring the Implementation and Adaptation of Evidence-Based Interventions (discussed and depicted in the previous section) considers various systems dimensions and influencing factors to predict success or failure of adopted evidence-based interventions in community practice settings. Given the research question posed, the social, political and historical nature of HIV/AIDS, its disparate
impact on communities of color and traditionally marginalized groups, and the need for new or adapted EBIs to be made available and accessible to communities, a qualitative research design provides the best approach for responding to these complex and interacting issues.
Sampling
A purposeful sample of three community-based organizations (CBOs) was employed. CBO’s were identified and recruited to participate in this dissertation research study. In purposeful sampling, “information rich” cases are selected to provide the greatest insight into the phenomenon in question (Devers & Frankel, 2000). A sample size of three agencies allowed for some cross- comparisons in the implementation/adaptation processes of MIP. Because MIP was new to CDC’s DEBI compendium at the time of this research, the selection pool of eligible organizations implementing MIP (approximately 6 across the U.S. and Puerto Rico) was fairly small. CBOs receiving funding from any source to implement MIP were identified via the following sources:
• CDC-DHAP was asked to identify organizations known to be either directly or indirectly funded to implement MIP. At the time of this research, only three (3) organizations received funding from the CDC to implement MIP; however, only two met the eligibility criteria of having implemented the intervention for six months or more.
• PROCEED Inc., a national provider of training and capacity building assistance in select EBIs including MIP, and the worksite of the Principal Investigator, had access to information on two additional community-based sites that were funded to implement MIP by non-CDC sources. These agencies had been trained in MIP by PROCEED and had contacted the agency for further technical assistance on MIP implementation.
• PI accessed the members of the original MIP research team to inquire as to whether they knew of any organizations implementing MIP, or had been contacted for information or technical assistance on MIP by any entity. An additional agency was identified through this source, however, it was unable to determine whether or not the organization had initiated implementation of MIP by the beginning of this research.
It is possible but unlikely that other organizations were implementing MIP without the knowledge of the CDC, the “gatekeepers” of these EBI intervention packages, or the original research team, as any implementing agency would have had at least some information and guidance on the intervention components and processes in order to actually qualify as having implemented MIP.
Sites were approached as potential participants for this research study prioritizing CBOs with current capacity to implement MIP with injection drug users. Following a suggested protocol outlined by Devers and Frankel (2000), the Principal Investigator (PI) first telephoned the agency Executive Directors, or other designated officials, at the indentified sites to request and secure participation in the study and initiate relationships. Calls were followed up with formal recruitment letters outlining the purpose of the research, the role, responsibilities, and obligations of the researcher and participating organization, the expected organizational commitment, the risks involved with participation in the study, and the potential benefits of the research to the organization and larger public. This correspondence included informed consent forms that required the signature of an organizational official to indicate an understanding of the terms, full agreement to participate in the study, and permission to obtain and review case files of clients currently enrolled in or having completed a cycle of MIP, with all identifiers removed. All recruitment correspondence was available to organizations in both Spanish and English. See Appendices A and B for copies of the Invitation Letter and Consent forms.
Study Exclusion and Inclusion Criteria
The exclusion criteria for this study were organizations that had been implementing MIP for 6 months or less and agencies implementing MIP with staff that had not completed the CDC- endorsed MIP Training of Facilitators. These specifications reduced the potential pool of participants to four organizations; one of which was unable to participate in the study due to a fire at the agency’s headquarters. Three CBOs met all of the following inclusion criteria and were cleared for participation in the study:
CBOs must have been implementing the MIP intervention with injecting drug users for at least six months.
CBO must have signed informed consent forms to commit to participation in the study and agreed to hold employees harmless from study results.
CBO must have had in place dedicated staff to implement MIP and to serve as a lead contact to this project.
CBO staff must have participated in, and completed, a CDC- endorsed MIP Training of Facilitators (TOF) prior to implementing the intervention.
The latter requirement, the Training of Facilitators are CDC-mandated prerequisite courses that agency staff must attend prior to implementing EBIs such as MIP. These courses train community-based practitioners and administrators on the interventions’ theoretical underpinnings, and main components and strategies, including how to conduct the intervention with the target population using scripted curricula to help support practice in the field. The TOF also provides organizations with detailed guidance around intervention implementation, especially with regard to the identification of core elements and key characteristics that must remain stable in order to maintain fidelity and thus, effectiveness in field settings. As part of the TOF, an MIP program implementation manual, inclusive of sample documentation and data collection forms and a mock
client file are provided to training participants to further support program implementation post- training. The MIP curriculum was available to practitioners in both English and Spanish.
Data Sources and Collection
Case study can be seen to satisfy the three tenets of the qualitative method: describing, understanding, and explaining. (Tellis, 1997, p. 3)
A case study approach using semi-structured interviews and document review was used to collect data for this research study. Although the study encompassed a predominantly qualitative approach, some objective data were collected to inform the creation of individual and organizational demographic profiles. A case study is “known as a triangulated research strateg[ies],” (Tellis, 1997, p.6) because it often uses multiple data sources to establish the validity of its processes. For purposes of this study a case is defined as a participating organization with multiple respondents affiliated with each case.
Table 4 summarizes the data collection methods used to answer the research question and accomplish the study’s research aims. Each aim is presented, followed by the methods and data sources used to address that aim. The data collection methods presented in the table are described in greater detail in the subsequent paragraph, including the justification for selecting a particular method and the strengths and limitation of each method chosen for this research study.
TABLE 4: Research Aims, Methods and Data Sources
Research Aim Methods Data Sources
1. Describe how agencies approached the selection of an evidence-based intervention such as MIP to meet the needs of their local communities.
Semi- structured Interview
Document Review
Key informant interviews- management and front-line staff
Two most recent reports to funder; Organizational brochures/ and/or description of services.
2. Identify the practices and strategies used to facilitate the successful adaptation of MIP in community settings;
Semi- structured Interview
Document Review
Key informant interviews- management and front-line staff
Behavioral Risk Assessment and/or Behavioral Staging Forms, Progress Notes; (2) most recent reports to funder.
3. Inform the development of user-friendly adaptation guidelines specifically for community practice settings. Semi-structured interview Document Review
Key informant interviews - management and front-line staff Progress notes
Data Collection
Semi-Structured Interviews
The semi-structured interview served as the primary strategy of inquiry used in this research study as it is one of the most important sources of case study information (Tellis, 1997). As noted by Creswell (2003), this type of methodology is useful for gaining a historical perspective, yet it allows the researcher to drive the questioning and provide structure to the conversations. Semi-structured interview questions were derived from the conceptual model (Enhanced Interactive Systems Framework for the Implementation and Adaptation of Evidence-Based Interventions), as well as the literature on the adaptation and implementation of EBIs. Semi- structured interview questions were developed by the PI, and then reviewed for clarity by both
members of the dissertation committee and community practitioners familiar with the administration and/or implementation of EBIs in community-based settings.
To maintain a degree of consistency in the manner and sequence in which questions were asked, a semi-structured interview guide was developed. In anticipation of the need to conduct