Mixed-method approaches to strengthen economic evaluations in implementation research

Abstract Background Guidance from economic evaluations on which implementation strategies represent the best return on investment will be critical to advancing the Triple Aim of health care: improving patient care and population health while minimizing per-capita cost. The results of traditional (quantitative) economic evaluations are limited by a remaining “qualitative residual” of contextual information and stakeholders perspectives, which cannot be captured by monetary values alone and is particularly prevalent in implementation science research. The emergence of qualitative methods for economic evaluation offers a promising solution. Main body To maximize the contributions of economic evaluations to implementation science, we recommend that researchers embrace a mixed-methods research agenda that merges traditional quantitative approaches with innovative, contextually grounded qualitative methods. Such studies are exceedingly rare at present. To assist implementation scientists in making use of mixed methods in this research context, we present an adapted taxonomy of mixed-method studies relevant to economic evaluation. We then illustrate the application of mixed methods in a recently completed cost-effectiveness evaluation, making use of an adapted version of reporting standards for economic evaluations. Conclusions By incorporating qualitative methods, implementation researchers can enrich their economic evaluations with detailed, context-specific information that tells the full story of the costs and impacts of implementation. We end by providing suggestions for building a research agenda in mixed-method economic evaluation, along with more resources and training to support investigators who wish to answer our call to action.https://deepblue.lib.umich.edu/bitstream/2027.42/146781/1/13012_2018_Article_850.pd

UUnderstanding Program Engagement and Attrition in Child Abuse Prevention

Engaging and retaining families is a common challenge when serving families at high risk. McCurdy and Daro’s (2001) Integrated Theory of Parental Involvement (ITPI) proposes factors that impact engagement and retention in services. While several studies have found varying family demographic and risk factors to be associated with family engagement in home-based services, (withheld citation for purpose of review) identified program and provider characteristics that predicted engagement and retention (withheld citation for purpose of review). Specifically, SafeCare (SC) had greater enrollment (4 times) and retention (8.5 times) rates than services as usual (SAU), likely due to SC’s skill-based approach targeting desired topics. As a follow-up to this quantitative study, we conducted separate focus groups with parents who engaged and who failed to engage in SC (N= 16) and SAU (N=18). Provider characteristics (e.g., caring, experienced with children, nonjudgmental) was the strongest themes for engagement across groups. Program and provider flexibility and providers’ persistent support for parents despite life chaos facilitated retention. Results suggest that provider characteristics and program approach are key in engagement of families in home-based services. These results suggest expansion of the ITPI to address social context. Results suggestfocusing on specific provider characteristics and program approach for work force and program development to increase program engagement and decrease attrition

Dynamic Adaptation Process to Implement an Evidence-based Child Maltreatment Intervention

Background: Adaptations are often made to evidence-based practices (EBPs) by systems, organizations, and/or service providers in the implementation process. The degree to which core elements of an EBP can be maintained while allowing for local adaptation is unclear. In addition, adaptations may also be needed at the system, policy, or organizational levels to facilitate EBP implementation and sustainment. This paper describes a study of the feasibility and acceptability of an implementation approach, the Dynamic Adaptation Process (DAP), designed to allow for EBP adaptation and system and organizational adaptations in a planned and considered, rather than ad hoc, way. The DAP involves identifying core elements and adaptable characteristics of an EBP, then supporting implementation with specific training on allowable adaptations to the model, fidelity monitoring and support, and identifying the need for and solutions to system and organizational adaptations. In addition, this study addresses a secondary concern, that of improving EBP model fidelity assessment and feedback in real-world settings. Methods: This project examines the feasibility, acceptability, and utility of the DAP; tests the degree to which fidelity can be maintained using the DAP compared to implementation as usual (IAU); and examines the feasibility of using automated phone or internet-enabled, computer-based technology to assess intervention fidelity and client satisfaction. The study design incorporates mixed methods in order to describe processes and factors associated with variations in both how the DAP itself is implemented and how the DAP impacts fidelity, drift, and adaptation. The DAP model is to be examined by assigning six regions in California (USA) to either the DAP (n = 3) or IAU (n = 3) to implement an EBP to prevent child neglect. Discussion: The DAP represents a data-informed, collaborative, multiple stakeholder approach to maintain intervention fidelity during the implementation of EBPs in the field by providing support for intervention, system, and organizational adaptation and intervention fidelity to meet local needs. This study is designed to address the real-world implications of EBP implementation in public sector service systems and is relevant for national, state, and local service systems and organizations

Coordination of sustainable financing for evidence-based youth mental health treatments: Protocol for development and evaluation of the fiscal mapping process

BACKGROUND: Sustained delivery of evidence-based treatments (EBTs) is essential to addressing the public health and economic impacts of youth mental health problems, but is complicated by the limited and fragmented funding available to youth mental health service agencies (hereafter, service agencies ). Strategic planning tools are needed that can guide these service agencies in their coordination of sustainable funding for EBTs. This protocol describes a mixed-methods research project designed to (1) develop and (2) evaluate our novel fiscal mapping process that guides strategic planning efforts to finance the sustainment of EBTs in youth mental health services. METHOD: Participants will be 48 expert stakeholder participants, including representatives from ten service agencies and their partners from funding agencies (various public and private sources) and intermediary organizations (which provide guidance and support on the delivery of specific EBTs). Aim 1 is to develop the fiscal mapping process: a multi-step, structured tool that guides service agencies in selecting the optimal combination of strategies for financing their EBT sustainment efforts. We will adapt the fiscal mapping process from an established intervention mapping process and will incorporate an existing compilation of 23 financing strategies. We will then engage participants in a modified Delphi exercise to achieve consensus on the fiscal mapping process steps and gather information that can inform the selection of strategies. Aim 2 is to evaluate preliminary impacts of the fiscal mapping process on service agencies\u27 EBT sustainment capacities (i.e., structures and processes that support sustainment) and outcomes (e.g., intentions to sustain). The ten agencies will pilot test the fiscal mapping process. We will evaluate how the fiscal mapping process impacts EBT sustainment capacities and outcomes using a comparative case study approach, incorporating data from focus groups and document review. After pilot testing, the stakeholder participants will conceptualize the process and outcomes of fiscal mapping in a participatory modeling exercise to help inform future use and evaluation of the tool. DISCUSSION: This project will generate the fiscal mapping process, which will facilitate the coordination of an array of financing strategies to sustain EBTs in community youth mental health services. This tool will promote the sustainment of youth-focused EBTs

Barriers to Accessing Treatment Services: Child Victims of Youths with Problematic Sexual Behavior

Child sexual abuse (CSA) remains a significant public health problem. Although the deleterious effects on the child victims could be mitigated through evidence-based interventions, victims often fail to be identified and receive clinical assessment and therapy services, particularly when they have been victimized by another youth. Given that at least a third of CSA cases are committed by another youth, understanding the process of identifying and addressing the needs of CSA victims of youth is the focus of the present study. Factors impacting services for child victims of youths with problematic sexual behavior (PSB) were examined through qualitative interviews (N = 226) with mental health agency administrators, direct service providers, and community stakeholders from eight geographically diverse communities across the United States. Responses focused on macro and micro level barriers to the identification and service provision for child victims of PSB of youths. Implications for clinicians and policymakers are discussed, along with strategies to enhance access and provision of services to meet the needs of the child victims