Pre-implementation Research Aim 1

Research Aim 1: Describe how organizations approached the selection of an evidence-based intervention such as MIP to meet the needs of their local communities.

The pre-implementation phase--characterized as the process of EBI selection and preparation activities conducted by an agency prior to the launch of an EBI-- directly correlates with Study Aim 1 which seeks to elucidate how organizations approached the selection of an evidence-based intervention such as MIP to meet the needs of their local communities. Pre-implementation phase explores the activities conducted by organizations to prepare for MIP implementation, the factors contributing to the selection of MIP as the EBI of choice for organizations, and staff perceptions of the intervention.

Key Finding 2: Community-based organizations expend significant time, energy, preparation, and planning into the selection of appropriate evidence-based interventions that complement existing agency services and meet the needs of their constituents.

A series of questions were asked of both management staff and front-line workers to assess agencies’ perceived levels of preparedness to conduct MIP and the pre-implementation activities executed by organizations to launch the intervention. Across the board, study participants were asked to rank on a scale of 1-5 (with 1 being the lowest and 5 the highest) their level of preparedness for implementing MIP prior to actual implementation. Two of the three agencies ranked themselves 4 or higher; whereas staff from one agency ranked themselves lower with a score of 2.2. Across all three agencies, implementation preparedness was associated with 1) experience with and knowledge of the target population of injecting drug users (IDU), and 2) having had prior experience implementing evidence-based interventions. The two agencies which self-ranked highly on preparedness noted

“being trained in MIP prior to its implementation” as one of the main reasons for a higher self-rating. Other reasons associated with perceived higher levels of preparedness included agency buy-in for the intervention, access to the IDU population, established trust between the agency and the IDU population, and the ability to link IDU clients to other in-house health, education, and social service programs. Although the agency that self-ranked lower on preparedness (2.2/5) had significant experience working with the IDU population and with implementing other EBIs, they felt less prepared for two reasons: 1) agency staff had not yet received the MIP Training of Facilitators (TOF) which prepares healthcare providers to implement the intervention locally, and 2) staff anticipated having a learning curve after completing the TOF and before achieving mastery with the implementation of program components.

In preparation for the implementation of MIP, 100% of study participants reported that needs assessments had been conducted by their respective organizations via a combination of methods including focus groups, community mapping activities, and consultations with key informants and stakeholders.

[Agency] held focus groups with former clients to discuss the possibility of implementing MIP. [Agency] discussed length of the sessions, incentives etc.

The agency had meetings to discuss what the potential of implementing MIP was. We decided to just go for it and select MIP.

Across agencies, other activities included staff training (n=5/9), protocol and/or policy development or modification (n=4/9), recruitment and outreach to the target population (n=3/9) and the development of memoranda of agreements to facilitate client linkages to other health and support services (n=2/9). Across agencies these pre-implementation activities included a combination of management staff, front-line staff and current or prospective clients. In one case, community partner agencies were involved in pre-implementation and assessment activities for MIP.

Factors in Selecting MIP

Key Finding 3: The most influential factors in community-based organizations’ decision-making processes for selecting appropriate evidence-based interventions for agency implementation included the needs of, experiences with, and the content, structure, and suitability of the intervention for the target population.

In order to gauge the extent of forethought and decision-making that went into the selection of MIP as the evidence-based intervention of choice, agency staff were asked about the factors that contributed to their selection of MIP for their organizations. In a series of open and close-ended questions, 7 of the 9 participants stated that the needs and service gaps of the target population were key considerations in the selection of MIP. Six stated that experience with the target population was also a consideration and almost half (5) stated that the content of MIP played into its selection as an EBI of choice for their agency. The comprehensive nature of MIP was also noted by (4) participants as a key determining factor in its selection.

Another one-third of those interviewed expressed that the values/norms promoted by MIP and staff expertise to implement the intervention played a role in its selection as the EBI of choice for their respective organizations. For two of the three agencies, existing trust established between the target population and the implementing agency was a factor in the selection of MIP for IDUs. In the case of one agency, staff felt that MIP had “local applicability,” and therefore would be a better fit than other EBIs within the compendium. Other influencing factors included the availability of resources, cost, client interest, community support, and “newness” of the intervention. Table 8 presents the most dominant factors noted in selecting MIP for agency implementation and offers participant quotes which further highlight these factors.

TABLE 8: Key Factors Considered in the Selection of EBI- MIP

Dominant Factors Supporting Participant Quotes on Key Factors Needs/Service Gaps of the

target population (IDU) MIP coincided with the community mapping conducted by [agency]. The MIP intervention seemed like a really good fit for [agency]. [We] used mapping data to direct our program efforts.

Previous experience with the target population.

MIP “offers more”/ MIP more comprehensive

We were already working with IDU and had some success with the target population. We were up for the challenge of taking on the new program. I saw MIP as more a benefit to the population we were going to be targeting because we were providing more services; we were offering more to them.

Content/Structure/Suitability of

MIP for IDU. Before [MIP] there was not a lot of case management, but in substance abuse you need a lot of case management b/c for instance if you have substance abuse and you are homeless you have to address the homelessness first….All the programs should have case management component. MIP brought the case management piece

MIP is the best model that is being implemented to work with drug users….

Individualized and client

centered nature of MIP [MIP is a] good match with agency because it is more client-centered. I thought they [IDUs] would be more inclined to try the intervention because we would be picking up their needs. [We] saw MIP as being more of a benefit to population we are targeting; offering more to them.

Trust established between

IDU clients and agency IDU clients already feel comfortable with [agency] as they have participated in other agency programs and events. We had the trust of the clients--no intervention goes out effectively if the client doesn’t trust you.

Perception of Intervention Compatibility or “Fit”

Overall, 100% of study participants believed MIP to be a “good fit” for their organizations. Many of the factors that informed an agency’s decision to select MIP as the intervention of choice also shaped staff perceptions of the intervention. Reasons provided by study participants regarding MIP’s compatibility with their agency’s current menu of services included:

• More comprehensive than other EBIs (n=3/9) • Harm reduction philosophy of MIP (n=2/9) • Local applicability/creation/context (n=2/9) • MIP is client-centered n=(2/9)

• MIP is individualized and provides “more” to client (n=2/9) • MIP is structured (n=2/9)

• Ability to provide wrap-around services to MIP clients through internal referrals to other in- house programs and services (n=2/9)

• Previous experience with other EBIs (n=1/9)

• Better match for the IDU population than other EBIs (n=1/9).

Across all three agencies, staff perceived MIP as an intervention that agencies had the capacity to do well and that would greatly benefit the IDU population and larger community. These perceptions aligned with the dominant factors reported by staff as influencing their agencies’ decision to select MIP as the EBI of choice for their organizations.

Upon implementation, initial perceptions that MIP fit seamlessly into existing agency services was challenged by a third of the study participants who felt that MIP was still a good fit for their organizations but simultaneously “a bad fit”. While none of the participants categorized MIP as a solely “bad fit”, once implementation began, supervising/management staff were able to identify characteristics associated with MIP that made seamless integration into existing agency services challenging, thus compromising “fit.”

• One agency indicated that the harm-reduction philosophy of MIP conflicted with the abstinence-based philosophy of other substance abuse programs within the organization that targeted the IDU population. As such there was confusion in the community about the

services provided by the agency, and hesitation to access services from some clients who preferred not to mix with active drug users, especially if they were in recovery.

• Staff across agencies articulated that MIP was too long and intensive an intervention for the IDU population. It was pointed out that due to drug use; IDUs are often unstable and inconsistent with appointments, thus making it difficult to retain them long enough to complete the MIP intervention. One Supervisor commented: “IDUs need a quicker intervention focused on treatment and primary and secondary prevention.”

Another agency felt that MIP’s “fit” with their organization was compromised due to a lack of knowledge by the funder of MIP’s philosophy, components, and how the intervention actually works in the field. As a result, this staff member felt that the expectations of the funder clashed with the goals of MIP as well as the agency.

Other implementation successes and challenges are discussed in the next section- Phase II, Implementation of MIP.