Sara Becker: Increasing the Uptake Of... Services for Youth Substance Use [via digital health]

Sara Becker: Increasing the Uptake Of... Services for Youth Substance Use [via digital health]

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all right so uh welcome to the cbitz webinar uh and being held in conjunction with the society for digital Mental Health um so once we get started um and I'll I'll introduce uh Sarah Becker here in a moment but once we get started please go ahead and put your questions in during the talk and and into the Q a and I'll read them off at the end um I wanted to just before we get started you know thank everybody for uh completing the survey so I wanted to just take a moment and give you the results of the survey that that people filled out uh a few weeks ago so I'll just share my screen here so um you know this is who the the the the people coming to uh the webinar are so not surprisingly about half our academic faculty and researchers and about a quarter our students but around 10 percent or from industry around 10 from Healthcare and then other uh and the other includes a few people from the federal government from law uh some staff people and some professional organizations uh and then the other reason that we uh sent the survey out was to you know think about what we want what people wanted for uh upcoming uh you know upcoming talks um and how do I Advance this here um so this is the results of what people wanted so um you know close to 90 we're interested in clinical science which is not surprising uh another 70 percent for design uh and the the other top ones around 63 for policy around 60 for digital health and this is sort of more broadly like disease management obesity and so this is something we haven't done and so we will look at starting to include more than just mental health but also more sort of digital Health uh and then you can see here what some of the others uh what the others are computer science Industry Health economics but I also want to mention here some of the suggestions so implementation science we will be doing some of that today um you know more talks on diversity uh and applications in community settings on accessibility um regulation and funding and then uh somebody also mentioned continuing education credits and that's something that we can we can look into providing next year I'm I'm not entirely sure if we'll be able to do that a number of people also asked whether they're whether they can get recordings and we do post the recordings so uh if if for uh speakers who agree to have their their talks recorded they are on the C bits website uh under under seminars I'll put I'll put a link into the chat uh once we once we get started so um so thank you for filling out that survey and uh now we can go ahead and get started uh we are you know I'm really happy to have Sarah Becker here talking with us Sarah joined Northwestern uh last fall she came from Brown and she came here to Northwestern to direct the center open found and and direct the center for dissemination and implementation science and she has uh you know her her broad Interest really is in understanding how to make that bridge between research and practice uh and and she works in a lot of different areas but her own research I think is centered largely in the area of of substance abuse and I think I think that's what you're going to be talking about today so without uh without further Ado Sarah so hi everybody thank you so much David for that introduction it's lovely to see some of the names of participants coming in a lot of friendly names and familiar names even though I can't see familiar faces um but thank you so much for having me here today it's really an honor um to be here it's a little bit intimidating to come after someone from Google that was a really exciting talk a couple weeks ago um but just thrilled to be here and to have the opportunity to speak with you about how to increase the uptake of effective treatment for youth um via scalable digital Health interventions and strategies uh this is not a topic that I talk about often I talk often about how to increase the uptake of effective treatment um but this talk today really challenged me to think about how could we use digital Health both as a highly scalable intervention that is readily implementable as well as part of your actual implementation strategy and your efforts to get something implemented into usual care so I had a lot of fun making this talk and I hope that we have fun together all right so I have some goals of what I'd like to cover today first I'm going to give you an overview of the what why and how of dissemination and implementation science so that we have some common language and Frameworks for the rest of our time together and I'm really going to challenge Us in that early part of the conversation to really think about how does the field of implementation science intersect with the field of digital health and what are some key points of contact and Synergy that we can think about to push this work forward then I'm going to take a deep dive into case examples I'll talk about two one specifically that was to create a scalable intervention for youth with substance use and the second which was to actually create a platform for HIV service providers to integrate screening into their usual care and that and that one the technology was really part of our implementation strategy and that's necessarily the intervention itself and then I'm going to end by talking about some resources and give you a Shameless very brief plug about our new center so without further Ado let's jump in so dissemination and implementation signs which will also hear me refer to as dni science for short let's talk about the what why and how so what exactly do I mean when I say dni science in the late terms I like to think about dissemination and implementation science as Bridging the Gap between what we know in terms of Public Health and Medical knowledge and what we actually do in terms of Public Health and Medical practice and I and our new center have been really intentional in articulating that even though we often talk about this as Bridging the Gap it's really multiple interrelated gaps that we have to address in tandem I also think it's really important to explicitly note that activities to bridge the gap must be proactive it must be intentional and we really have to Center Equity to make certain that we're not simply increasing access to treatment for those that already are most likely to receive it but that we're really thinking about Equity as part of our implementation science activities so the National Institute of Health act and just be a be as reassured I just showed you some circles and gaps I'm going to talk about each of those in turn in a moment first I'm going to give you the high level view of how the National Institute of Health defines dissemination and implementation science or the D and the eye dissemination research is defined as the scientific study of how to distribute information and material to a specific audience for public health practice I like to think of this with my economics hat on in a former life I was an economics and Psychology major and so I like to think of dissemination research as research broadly to increase the demand for Effective Health Services we can think of this as addressing a specific Gap that I will call the public health demand gap which we'll talk about in a moment implementation research on the other hand is much more context specific this is the study of the use of strategies to integrate a specific Innovation or Health Service into a specific context or setting again with our economic pattern this is work to increase the supply of effective treatment out in community settings and I would argue helps us to address our Public Health Supply Gap why do we need this type of research why are these gaps important I like to answer that with a visual metaphor of the behavioral health treatment system which is actually a photo that my husband and I took on a helicopter tour of the Grand Canyon many years ago and I love this picture in this metaphor because what you see is one enormous Canyon but it's not just one singular thing it's made up of multiple adjacent gaps that combine together to form something of a really Grand scale and I think our health systems like that too it's not One Singular Gap that we're addressing but multiple problems silos issues that we are addressing in tandem so let's talk about those gaps that I teed up for us in the bridge picture before the first Gap is what I would call the public health Supply Gap that in Lay terms is really the gap between the care that could be available if we used our best public health and medical knowledge versus the care that actually is available in the community I think most of you that attend this seminar I probably don't need to convince that this is a big issue but if I needed to there's a trio of landmark Institute of medicine reports that really document this Gap and they actually call it crossing the quality Chasm and I just love this word um chasm in one because I have a serious word alert and Chasm is a fabulous wordal word but also um because it really again gets at the enormity of the problem it's not simply a gap it's a chasm like this is this is something of an immense magnitude and these reports by The Institute of medicine document the scope of this gap between what we know and what's actually available and it also knows that the Gap tends to be even greater for the treatment of mental health and substance use conditions because of the number of unique barriers in those systems such as the stigma Associated um with providing care and receiving care and there are also some statistics I like to highlight right up front one is that it takes 17 years to turn 14 of in original research to the benefit of patients often when I present that statistic people are like wait wait what does that mean it means that 86 of our research does not help patients and that the research that does help patients on average take 17 years this should alarm you it alarms me and it suggests that we really need to be working to accelerate the impact of our treatments I also love this quote by fixing and colleagues that affected interventions without implementation strategies is like a serum without a syringe secure is available but the delivery system is not and I view that quote as a really nice reminder that it's not enough to just create beautiful elegant effective treatments we have to be really intentional about thinking about how are we going to get those interventions out into the community that we're not just creating serums without syringes but that we're really creating the whole package all right so back to this is what I would call the public health demand Gap this is the gap between those who need treatment and those who seek any treatment at all this doesn't even get into whether that treatment is effective but if we just look broadly at the percent of Americans that meet full diagnostic criteria for a specific issue who receive any health services at all my goal on this slide is simply to show you that the number should be 100 or at least pretty close to it and they're not for a substance use disorder only about one in five or twenty percent of people will speak any Services that's even lower if you work with youth it's usually about five to eight percent for mental health less than half of people will seek any Services those with HIV only about two-thirds those are the physical disability of high impairment only about 70 will take any services at all and when you peel back the layers of the onion and look at who is getting Services the level of unmet need is greatest among those with lower education lower socioeconomic status and from historically underserved groups so really those that we both want to be reaching with our interventions are the least likely to receive any care at all so again the public health demand Gap is a huge part of the issue I like to just always note that if you think about the covid vaccine rollout as just a really Salient example I think that's a great example of how you need both sides of the coin you need to address the supply Gap you need to get shots out into the community but you also need to get people out to actually seek the vaccine and to go and get the vaccines you need to be addressing demand and I would argue that our government did a pretty decent job on the supply side getting shots out into Community we didn't really address demand we didn't think about how to address medical mistrust we didn't think about how to increase knowledge and awareness in the communities that most needed it and so our efforts fell short so I would argue we really need to be doing both things in Tampa all right and then very briefly there are two other gaps that I think are critical to address one I would call the expertise capacity Gap and one I would call the scientific or methodological Gap that's basically what I'm trying to say here is that the field implementation research is relatively young I attended the first NIH training institute implementation science in 2011. um the field the Frameworks have only been around for about 15 to 20 years I mean many people have been doing this work for a long time but the actual field has really only coalesced in the last couple decades and so what you see on this visual here is one example from one funding Institute the National Institute on drug abuse they did enormous investment in addressing the opioided stimulant epidemic in the last five years of 2015 to 2019 and what I just want to highlight was a detailed analysis of all their funded grants suggested only 1.5 percent or what we would constitute as implementation research so this field is wide open um there's still not a lot of implementation research there are not a lot of implementation researchers so one of the things I hope our new center will address is really addressing this expertise capacity Gap promoting training and education and helping to build the workforce so if you are listening and you are interested in this field but haven't leaned in yet we need you um we really could use your talent and so I'm happy to talk with folks after this presentation if we can help move you into this field so why do we so like what is what are some of the status quo issues that perpetuate these gaps one is that we have a very linear and flow model of how we conduct research we typically start with what to Target then after we do our pre-intervention studies we think about does it work under highly rigorous conditions then does it work in the real world and only at the last phase do we really think about how do we deliver this how do we get it into the system the argument I'm going to be making today and that many in the field of implementation would make is that we should be thinking about that final step throughout the process we should be thinking about how to deliver how to design for scale you know how to work within the contact contextual barriers that we Face to actually be creating things right up front that have better potential to be adopted so usually this is where I talk about the how of dissemination implementation research so I'm going to tee this up and then I'm going to challenge us to think about points of intersection with digital health so the how of dissemination and implementation research I think is easiest to think about when you think about first the status quo so the status quo we typically think about a specific Health Service or innovation and we think about its effect on patient outcomes like symptoms like functioning or their health status what that ignores is a heck of a lot of contextual variables around like what is the climate where we're delivering this what are the policies at that time that might support that intervention or Health Services being adopted in routine care who are the people that are going to deliver it it also ignores the strategies that we would use to actually get that into practice like do people need training do we need to provide incentives for them to deliver this service like what types of specific strategies are needed it also ignores a host of important outcomes like is this feasible for people can they deliver it with Fidelity um what does it cost to deliver it and a whole host of service outcomes like is it efficient is it patient-centered and is it timely all of these variables in the middle and around the perimeter are what we would say is the core of cni research so I'm really in preparation for the talk was just trying to think about what are some points of intersection here with digital health and the first is that it's been well documented there are unique barriers and facilitators to digital Health that might not exist for other tools for one you know is tech support available for the tool what is the digital literacy it's the population that you want to work with you know does that population have specific concerns about privacy or confidentiality there might be specific facilitators as well such as teenagers that are chronically on their smartphones so these are all things to think about when thinking about designing a roadmap for yourself also our intervention becomes different as opposed to a Health Service that's delivered by a human you know suddenly we have a suite of digital tools that can help us to increase the reach potentially of the services that we're creating the strategies themselves differ too so for implementation strategies there's a whole host of strategies that we often talk about a common taxonomy you'll hear with the experts for recommending implementation change or inter I'm sorry it's the Eric's taxonomy but there are unique strategies for digital Health tools like you might need a strategy to identify patients that need this tool you might need a referral mechanism in your health care System you also might want to think about these outcomes in a slightly different way how you think about the Fidelity of intervention of the intervention might be a little bit different in the digital tool and you might actually think about the Fidelity delivering it to the person or getting them to the app as opposed to Fidelity within the app itself you also might think of your service outcomes a little bit different in terms of how you measure efficiency or timeliness these are areas that actually some wonderful leaders at Stevens have really been pushing the needle forward on so I just want to share that if that's something that interests you um David who was here and his team Andrea Graham Emily latty and others have really published thinking about what are some unique implementation strategies for digital mental health interventions and also some colleagues Steve Schuler with formerly of Stevens as well has really pushed forward our thinking of how do we re-characterize our established outcomes so this is an area that I think is really exciting and right for us to be thinking about I'm going to spend the rest of our time talking about two case examples from my own work that have gotten me thinking about this intersection of digital health and implementation science and first is one that I think is a little bit easier to maybe wrap our heads around and it's just how do you think about designing a scalable highly implementable digital Health intervention right up front this was a project that took place in partnership with an adolescent residential facility that provided both substance use and Mental Health Care the rationale for the study was that adolescence and residential have the most serious problems and functional impairments as opposed to other levels of care and the good news is that recovery is possible but the end the bad news is that ongoing support is really critical to maintaining that recovery and people tend not to use it so residential treatments associated with encouraging reductions in substance use and co-occurring mental health symptoms but the long-term results really tend to fall short we see that about half of adolescents relapse with within the first three months of discharge in part because alarmingly only 35 to 45 of Youth that just had a residential stay will receive any continuing care at all so there's a big gap between Continuing Care need and continuing care receipts and so we really wanted to try to think about how to address that there was a call by the Residential Care Consortium that residential facilities should really prioritize parent engagement and that noting that parents are key part to that recovery puzzle and there is another place where engaging parents is immensely difficult so we really wanted to tackle this and think can we design a scalable parenting intervention that would really help adolescents with that Continuing Care Challenge and the fact that so many adolescents fall through the cracks during continuing care so rather than recreate something ourselves we look to the literature and we said hey are there effective health services that exist and there was one there was a highly scalable program called parenting wisely it's an interactive parenting program that programs can purchase for their patients or patients can purchase for themselves it's about thirty dollars per license fee but you can get a discount if you bulk order and this has been shown to improve parental monitoring and communication which are two key processes that are associated with adolescent outcomes after residential treatment and it's also been shown to improve the youth actual their behavior themselves but with a focus on behavior problems and not on substance use or mental health so we thought okay maybe we could just offer this to people and see if that would help but we started by doing formative research with parents with teens with residential staff just to ask hey if we were to offer this to you would that be something that you'd even be interested in that you would consider using and we heard some interesting things um and this work was done ages ago as part of my k23 which was funded back in 2012. this is something I was actually doing for another purpose I was doing qualitative research um to try and improve the marketing of treatment but I when I was doing that type of research in a residential facility I started hearing all this need from parents about this mismatch between when they wanted treatment and when they were getting it so that sparked us to really think oh could we improve the service Point here where we're hearing all these pain points could we actually help this population so we started by just talking to people which is what I think often we should do in research more and we heard some really interesting things we heard people really want a guided delivery parents were saying I am a dinosaur with technology if you just give me an app I will not use it I need you to hold my hand and really teach me how to use it show me how to use it until I get a certain level of comfort people also really really wanted to connect with parents some of our work was actually done in focus group formats and parents were saying in the group this is what I want I want more of this more opportunity to connect with other parents people were also saying I don't want to wait uh once a week to have to go in and talk to someone I want advice when I need it people were also saying they wanted to be reminded to use the app so they wanted push notifications and daily text messages privacy was very important they really wanted this to start while their team was in residential and then we heard some very unique strategies to implement from the staff themselves they were saying like we really think that she would need to be integrated into our intake process and would be something that would happen right up front that we would initially Target and be able to identify families that would benefit from this and just routinely offer this as part of the intake or else this won't happen so we did a very small say and this was funded by an R34 a few years back um where first we were just being okay could we build something that parents might like what we did was we developed an app that was very simple it just had two forums it had an ask an expert Forum where parents could ask any type of questions to a parent and a form where they could connect with other parent s this um and it also had daily tips of the day where parents got links to the videos that were from that parenting widely off-the-shelf programs there was very little we had to create here we were basically just bringing people together and connecting them with an expert first so spatially speaking our initial app really fit here this is a framework from the paper I showed you earlier about recharacterized outcomes this is a guided behavioral intervention technology product the reason I all book circles fully automated is that when I think about this product from the perspective of a residential facility it was very clear to me that residential staff could not take this on there was no way that they could build for Parental Services easily they really weren't motivated to do this so it needed to be automated from their perspective they needed to be able to purchase an off-the-shelf product so it is guided in the sense that if an agency were to purchase this product they get access to a coach but the vision for the business model is that it is automated from the perspective of the residential facility fun sidebar when I was submitting a follow-up Grant to this the NIH actually required me to make a business plan before they would fund this the Services Research branch chief said you know we're not funding digital Health unless there's a business plan for how to do this so happy to talk about that in the Q a because that was something that I thought was really interesting to see that focus on scalability so this was an R34 as I mentioned our aims were really to see was this feasible was it acceptable to see if it helped parents and if we had a sense it was actually targeting the parenting processes we thought um this is a consort diagram the takeaway that we had to assess 209 to randomize 61 and the main reason people were excluded is they had no history of use this is a busy numbers slide what I want to emphasize here are that these are happy numbers so this was a grant where we actually pre-specified goals we said we will believe this is feasible if a certain number of parents enroll if a certain number of parents are retained if a certain number of parents post and we met or exceeded all of our benchmarks so my takeaway number is that I'm sorry my takeaway message was that we were exceeding all our benchmarks we had good signs that this was feasible and acceptable to parents I think the most happy numbers on the slide were that parents that got this very light touch intervention were much more satisfied with their overall experience of Residential Care than parents who didn't um so that alone when I spoke to the residential chief medical officer was enough that he said we really want to offer this to all our parents because this light touch thing that doesn't cost a lot of money you know makes them more satisfied and more likely to recommend our residential treatment to a friend these are some graphs just showing our preliminary Effectiveness outcomes the takeaway was that this light very light touch intervention for parents we saw that teens whose parents got it did better in terms of their days of drinking and also their school related problems over time we also looked at a host of parenting outcomes and we did this both with questionnaires and by watching parents and teens interact and coding their interactions we saw lovely interactions exactly the way that we would want to see that parent communication limit settings parents ways that they told teams about their substance use beliefs the way adolescents were disclosing the way parents were monitoring all improved overtime so this was a really successful pilot project which led us to apply for an ro1 it is now funded as what's called an r37 which is a mechanism that Nida makes eligible for 10 years of funding which is hugely exciting but basically we were successfully funded and we are now doing a larger follow-up of 220 our logic model is that we want to speak in our off-the-shelf scalable program um really improve proximal parenting outcomes as well as adolescent outcomes at the end and I just want to show that we did improve our interface it's still very simple this couldn't be a simpler app this could be also available via website um but basically it's just a forum for people to come together and talk we did also make some new app settings in response to parent feedback in our first one of the coolest is that you can toggle in between English and Spanish to view posts and so someone posts in English it's Auto translated and you can actually like respond in Spanish and they'll fade in English which is really neat and the great news is parents are using this we are actively in this study now I think we've enrolled our first like 30 something patients but we're at a very big clip we have a recruitment goal of four parents a month we've been exceeding it wildly since we've started here at Northwestern in August and just recently a parent posted hi I'm new I appreciate everyone's honest vulnerability I've been reading the experiences and I'm astounded by how I felt we were the only ones although intellectually I know we're not I have a coaching session soon and reading all the common questions have provided some relief relief that I'm not going crazy and I'm not supposed to be the super strong person who can deal with this and be alone so as a pi this is like why we do this it's so lovely to see parents actually engaging with each other actually using the app actually helping each other um again very light touch very scalable intervention um and I mentioned business model before our hope is that this would actually be a product that residential treatment facilities would purchase as opposed to having parents purchase this so it would be something that would be offered as part of the intake process as an ancillary treatment for parents if they would like um and it would actually be in the bundled rate for residential services we are working with the largest residential facility in the country right now which is Rosecrans Health they're actually right here in Illinois so my move here was very convenient because I'd been working with them for a long time and they are very bought into this and interested in actually purchasing this at the end of the study so hopefully that will be something we'll be able to continue all right so now I'm going to take a hard right and give you a very different case example of how might you use digital Health Products to actually think about helping the workforce to deliver an intervention so not necessarily just giving an intervention that is digital that patients can use but to actually layer something in into the actual workflow using a digital Health System this was a project that came out of work that my colleague Caroline quo was really leading in South Africa to address the HIV epidemic um this visual here is just to show you that all of South Africa's red this is basically a heat map of the HIV epidemic to show that South Africa is really at the epicenter and my colleague Caroline has been doing work there for two decades and basically I had experience leading a national or Regional training and technical assistance center and in 2017 there was a call for proposals to actually create a training and technical assistance center in South Africa so my friend Caroline and I partnered thinking I have expertise leading training and technical assistance center she has expertise working in South Africa to address HIV let's partner together and see if we can help the HIV Workforce to learn effective Behavioral Health treatments and so this project really came out of that partnership um I really think some of the best science is just an excuse to spend more time with your friends um so this is really a kind of a project that is my you know uh Valentine's letter uh to Caroline but basically of the work we were doing was really centered around the 90 90 cat targets for AIDS reduction in South Africa where which at the time South Africa was doing decent having people be aware of their HIV status where they were really struggling was that only 68 of people that were aware of their status were on HIV treatment and they also struggled somewhat with getting folks a virally suppressed but it was really this second 90 Target that was starting to get a lot of national attention and it was really coming to their attention that alcohol use was a key driver in this challenge South Africa has very high rates of alcohol use it's one of the kind of hot spots globally for fetal alcohol syndrome and it's been linked with problems in the HIV character care Cascade across all of these targets it increases the likelihood of infections specifically really affects retention and treatment and likelihood of seeking care it also accelerates disease progression so we really wanted to see if we address alcohol use and detection of alcohol use could we help with HIV care Cascades but South Africa has unique challenges that I think make digital Health um really interesting to think about one is just a dire Workforce shortage over 30 percent of South Africans experience a mental health issue such as depression anxiety or substance use disorder in their lifetime in fact our colleagues at University of Cape Town really led the first national prevalence study documenting these rates where they were going door to door throughout the country to really you know get a handle on what the prevalence was um but there's not many people to treat it um in globally there's usually nine people for every hundred thousand people um so there's nine Personnel for every hundred thousand persons that need mental health that sounds low to me but in South Africa it's .08 to 0.89 so for every 100 000 people that need mental health services there is less than a tenth of person and on the low end and up to one person on the high end so just an enormous shortage for this reason of an approach called shifting has become very popular in South Africa and other low and middle income countries it's basically a solution to the healthcare Works Force shortage by training um basically training non-health professionals to train other leg counselors to deliver something so it helps make the approach scalable by actually using a Workforce that isn't your typical Workforce so we're not only relying on you know PhD level folks to deliver stuff but we're actually relying on community health workers and folks that are invested in care to really increase the scale of our work this was developed as I mentioned in response to a call to expand training and technical assistance centers back in 2017. and funded by samsa and the

president's emergency plan for AIDS relief at the time the very first thing we did after we were awarded at the South Africa attc was A needs assessment of national stakeholders these were all the heads of Departments of Health in each province in South Africa heads of major ngos leading HIV service organizations and we actually asked them what do you need what do you need to address the HIV epidemic and we really heard we need alcohol screening and we need drug screening and then we need brief interventions once people are noted so that's really where our desire to focus on alcohol came from was really from the consumers and and sorry the partners themselves so there was also right at this time nationally a lot of policy momentum the national Department of Health was really interested in this so we as part of our new National Training and technical assistance center convened a policy Forum focused on screening and brief intervention where we brought together National stakeholders and policy makers um fun fact I was there on my 40th birthday so there's some photos of all of us together in South Africa that's really exciting for them and what really came forward at this National forum is people were like we need a scalable delivery platform that works in low bandwidth settings that folks can access in any place and folks really thought like we also need a way to measure this so that's where technology started to be brought up is can we use digital solutions to actually bring this to scale across the country so our goals were really to develop a train the trainers implementation strategy that was very scalable and that huge technology as integral to the strategy itself and then we wanted to look at did we have some indication that this was effective this was really happening on the national level so I like to view this as an implementation evaluation study of a national momentum and National initiative that was already going to happen whether we were on board or not here's our visual model our evidence-based practice with screening and brief intervention our strategy was a very scalable train the trainer model that used digital tools as integral to the model itself I'll tell you about it in a moment and we wanted to look at first could we train trainers to a certain level of training Fidelity like would they deliver our training materials with Fidelity could we get them up to a certain level of knowledge that we felt really comfortable in their understanding of the materials could they then go on to train providers in a way that would change the provider's attitudes their confidence their willingness to deliver this intervention and would we then act actually see reach throughout the country of the screening and brief intervention that we were helping to build their capacity so our first we spent the first year of this project just developing our scalable train the trainer strategy our goal was to really create engaging visuals that could be used by folks that had low literacy and that would be totally off the shelf we had slides if folks had PowerPoint but we had contingency plans for our contingency plans my colleague Caroline would always say like what if it's in a rural region you know and there's no electricity the day that we get there you know so we had like handouts that could be brought that were super friendly we also had PowerPoint slides you know this was really meant to be a scalable training protocol that was only a couple hours we also really use technology as integral to the train the trainer approach itself and I'll be honest I struggled here when talking to you all of whether to call this an implementation strategy or an implementation delivery platform because like we ended up delivering the expert through a trade a technology platform um but I'm calling it part of our strategy because it didn't exist before we got there and so we had an intervention that exists we had screening tools that had been shown to work in South Africa called the audit and the dudit and our solution was how do we get that into practice and part of our strategy was we have to bring this onto a technology-based platform or else it's never going to happen so we helped we worked with a partner we started with one called tbhib care we invested in a system called com care and we created a very easy user-friendly interface to actually go through these screening tools most importantly we integrated it with what they were already doing so this wasn't a standalone thing of like oh now it's time for me to screen for alcohol let me get out my tablet we moved our entire screening process onto the tablet so it was something that was actually happening as part of their usual workflow and not an additional thing that they had to do but truly truly integrated we also had a technology training where we trained people in how to use the technology and we did that both for the master trainers and for the provider so let me just really quickly give you some signals of does this seem to be working our goal here was could we bring this to scale and I would say yes our initial data is that yes we can um we trained only 11 people those 11 people went on to train 211 people um in the last one of our last data draws they had over 45 000 patients had been screened for alcohol um you know within these HIV service settings so that's just outstanding um and in fact my colleague Cara recently sent me some data that but in the last three months I think another 20 000 patients have been screened so I don't have those data to show you today but we're up to about 65 000 screen so really very very very exciting stuff um so let me just show you some of the glimpses of what we're seeing here what we're seeing is that trainers can be trained to very high level of fidelity so these are trainers without extensive education or background these are not folks that are your typical efficacy or Effectiveness study type of providers um and they're covering 99 of our training element as observed by our team objectively we had someone go out and observe that you know did not have you know uh specific allegiance to our program so we had research staffed trained to observe um very high skill ratings as well very excitingly and we trained those folks trained 211 providers another 43 providers that we didn't train ended up kind of coming on board to the project later and just by virtue of using the technological tools that we developed we're able to kind of jump in and start delivering experts and what we saw here was just really exciting data we saw High rates of adoption um overall looking at the rate of adoption versus the number of people we train versus the number delivering at the end it was 85 due to untrained providers coming on board we also saw increases in provider knowledge also this is some of the best retention I've ever seen in a study and I think it was partly because of this master training Cascade model the master trainers really made relationships with the people they trained and could then help and actually distribute our surveys via WhatsApp um to the folks that they've trained so I mean these retention rates are just outstanding um and so we saw knowledge go up significantly from pre to post training we saw attitudes we measured what are people's attitudes toward delivering experts we saw the attitudes go up and this was in the 211 so this is not a power issue from the 4500 this is a 45 000. these are just the 211 providers that we trained but we saw confidence um go up some of our attitudes were not significant did see that go up but the attitudes were pretty decent when we started but we felt confidence go up significantly which is great we also saw people's perspective of what this acceptable feasible and appropriate in their setting increase over time I could have a sidebar here that if you are in the implementation science field and use these measures there tend to be stealing effects that people always start pretty high people say like oh everything's acceptable everything's feasible everything's appropriate so I did not expect to see much here and I was delighted that even though we started pretty high on a five-point scale we went even higher over time so that was very encouraging um and most excitingly patients are actually being screened we're seeing enormous numbers of patients being screened High rates of appropriate screening and brief intervention so um just to show that our approach can work you can do scalable train the trainer models and Technology can be an integral part of them so I'm going to conclude our last few minutes which is the Shameless plug of our new center I have my beautiful mug here fetus the center for dissemination and implementation science we were established on August 1st this 2022 and we are really Guided by three strategic pillars on a platform that our primary function is really to coordinate the great science that's already happening so there will be r at Northwestern but also and Beyond in the field to really help be a Nexus of exciting implementation science work Central to our mission statement is to advance Equitable access to evidence-based Public Health and Medical interventions because as I mentioned if you're not implementing with Equity first and foremost you are likely going to heightened disparities and you really need to be intentional about centering equity in your work and then our three specific goals really align with three specific strategic pillars the first is scientific leadership our goal is to accelerate the impact of research across the translational Continuum the second is support and service we really want to help train the next generation of dni Public Health researchers and practitioners and as we can say here as friends webinars like this are great they're really wonderful for increasing knowledge familiarity but often a lot more is needed so you know our hope is to create kind of ongoing touch points courses programs that people can come together and really immerse themselves in this way of thinking and then finally we want to serve as a training and educational Hub um also somewhat related to the support and service that I talked about before I feel like those really go hand in hand we're going to train and educate and also support the people that are doing this important work um within our new center here at Northwestern we have two brand new center Grants one awarded on August 1st and one awarded on September 30th these are both funded by the National Institute on drug abuse um drug abuse kind of sidebar stigmatizing language hopefully that will be changed it really ought to be persons with drug use disorder but anytime I say the funder I always cringe um but the National Institute hopefully someday up on drug use benediction but one of our programs is based out of Stanford and it's called CBS Center for dissemination and implementation at Stanford and the other is funded as part of a new Nida data to action program they Center the rack is so fun for me because our goal is to work with Nita funded grantees that are not planning to do implementation science and help them Infuse implementation science thinking into their work and that's really like where my heart is I love when folks aren't thinking about implementation science just being that friendly nudge of like well maybe you could just lean in a little bit by thinking about this or maybe you could lean in a little bit more if you just did this other little thing so um if you ever need a friend to encourage you to lean into implementation science that's my jam I would be happy to help do that for you and then on the right here is just a visual of some of the work that guides these two center Grants I think we could probably all agree that in a standard clinical research Paradigm we are often testing interventions and their effect on outcomes but like the how so like you know which component of our multi-component interventions really drove change is often a black box um I think I and my colleagues at these two centers would argue that in a standard implementation science Paradigm we tend to replicate a lot of those same problems so we take a broader lens we look at the intervention and its effect on outcomes we look at a host of other things like our barriers and facilitators the systems where people work we look at different outcomes but the actual how how does our strategy work if we have a multi-component strategy like the one I just described is it the technology that's driving it is it to train the trainer materials like really specifying and measuring with intention is something we don't do enough in the field so we are really working in these center Grants to really try to advance the field of implementation strategy selection specification monitoring Fidelity tracking so that's certainly an area of interest of mine that I'm also happy to talk about during the Q a so to end um I always like to acknowledge my team and usually I end with a bunch of uh just names and words but many of these folks moved across the country with me either from Brown University where I had spent the last 13 years or folks moved for the opportunity to start a new job and build this new center with me so I just wanted to show photos of folks that took that leap of faith and were willing to move here I also have a number of colleagues across some of the projects that we've talked about today the South Africa project is called Arch the parent smart project came out of both the k23 and an R34 and an r37 mocha most of the folks of which are up here also do some work with colleagues through a network called first and then I also mentioned the two new center Grants this is just the sampling of some of the active grants we have at cetus but these are the specific grants that we talked about today and I think we met our goal of having about 10 minutes or so for questions so I will stop share and let's say come back and hopefully we can take your q a all right Sarah thank you for just a fantastic talk and uh folks if you want to start putting in questions we already have quite a few and we will get to as many as we can so uh start off here from jeffreyville uh I think this is your earlier intervention how did you do the translation while sustaining privacy within the environment um did you send it to a third party uh in the process I'm not sure what that means how do you think you you mentioned that you had a trans you translated one of the apps into Spanish or the communications back and forth and so oh so we actually had a Google uh plugin so it's kind of a clunky translation to be honest but we Orient people to that so one of the nice things about having a guided intervention is that folks get coaching sessions um which again would be part of like a purchasable product that's how we're viewing our intervention it's kind of a a system that a residential facility could purchase and as part of that we provide ba level coaches um ba or Master's level coaches that work with folks and they actually will tell them like you know so if you talk to someone in Spanish you know be aware that the language might be a little bit broken but there is this kind of translator that you can just turn on right within the app well so they they okay so they choose to turn it on yeah yeah um and I think you've sort of answered this next question from uh Dan Adler uh you know about the the business case uh and so he was basically asking how do you navigate the tension between a uh you know have needing a a coach uh and and not being able to integrate that into the care setting yeah Dan I like early on in um my career when I was writing that R34 we had a talk from the folks at Vermont um Lisa who directs their big p50 focused on behavioral intervention technology came he gave a talk at Brown and like overwhelmingly her work was suggesting that using technology as an add-on was a thing that providers really like and that patients really liked and so we felt like so that was kind of in the back of my brain that we know that that's an effective approach and then when we spoke to the parents it was so clear that they said if you just give me an app um we won't use it and I didn't even mention that but in my preliminary studies for my R34 we tested with eight parents we just gave them the uh parenting wisely programmed no one used it the modal number of logins was zero and so having a coach seemed to be a critical way just to get people to even use the app um and so then we really did struggle when designing this study with the residential facility of should we train your staff to be the coach and you would actually bill for this and integrate but they were pretty clear like can we just pay more um so that was actually the chief medical officer said we just pay to buy this app from you and you know have someone in the app that actually was um would produce the coaching session see how we're going to do that is going to be the next phase of our project so I have the luxury that this was funded as an r37 which means that at the end of the third year we apply for an additional five years of stable funding and 100 we're going to be testing all delivery strategies costing cost Effectiveness in that final five years because I don't know how to do it just yet but I feel like that's what we need I think I think we're seeing that across the board that uh you know being able to integrate these having staff take on these extra duties just does not does not function that a lot of companies now are offering the the support services along with the the product um so uh another one from uh from Jeff here um would you agree that the number one implementation objective is to scale delivery uh to de-skill I'm not sure there's many but the the human in the loop so the lower uh the lower cost carers can be brought online uh or do you think it's uh more important to use digital to scale the productivity of skilled clinicians I think my bias is probably the latter um that I'd love to see digital use to scale the productivity of skilled clinicians and actually bring more skilled clinicians to folks um one of my husband and my good friends I'm not going to stay specifics but it's likely to take a company public soon and make a lot of money bringing an experienced um carers to scale and I debate with her all the time that I'm not sure that's ethical or that that's really helpful so um yeah I can understand the desire to build the capacity like in South Africa that was the workforce we had so we had to build their capacity to deliver interventions um but we could do it in a way we could use technology in a way that helped them to do so with Fidelity I think you know when you have access to skills providers I'd love to see the technology allow the skilled providers to increase their productivity as opposed to replacing them all right uh from uh Jin sheilai uh could you please define scalable so oh my gosh that's such a good I don't know if I can do that Justice um one of my colleague Lori descharm has this beautiful talk about like scaling in versus scaling out and the differences about them we have a reading Force where we have a whole week dedicated to defining scalability I think I'm going to dodge that question and send David some references to send when the um when this is posted this video because there's some really good thought pieces about like what exactly is scalability and what is scaling out versus scaling in when I use it I'm just using it in a lay language of like is it something that we could really be taken to multiple organizations or to multiple places all right uh from uh William lever uh thanks for a wonderful presentation you're implementing a brief digital intervention in an academic medical setting do you typically recommend using multiple implementation models and Frameworks I.E FSC for re-aim that's a great question we just had our dissemination implementation reading course yesterday we had a section on series models and Frameworks and our view is that you know all models are all models are wrong but some are helpful and we joke that the only incorrect model is one misapplied I tend personally to use multiple so in one of my recent grants I had used epis as a process model I use C4 as a determinant model and then I also had re-aim to help think about evaluation you don't need to use that many models I usually recommend just thinking about what your goal is and there's different goals of models you can use models to talk about the process you can use them to talk about what is actually happening or you can use them to evaluate so it's really just understanding what your goal is and then picking the right model because we could talk about that for an hour foreign Morris thank you for a wonderful presentation I appreciate the definitions you provided the dissemination and implementation how you would would you define research translation and how is it related to implementation and dissemination so that's another great question our ctsa is really um working on our renewal actively right now so we talk a lot about what is translational research what adverse is what a translational science and then you use the phrase research translation which I'm not sure exactly what you mean and if you were abled on you I would ask you um but we think of translational researches research kind of along the translational Continuum that helps you to think about you know how to improve the process of translation but then translational science is the how so it's the how do we move our research like across the Continuum as we're moving from efficacy to Effectiveness the dissemination and implementation science so I think of dni as a key part of translational science it's the methods of the how we bridge the gap from research to practice and I would argue if you're using dni principles throughout the translational Continuum it's very much harmonious with what translational science is meant to be from Muhammad Hassan thank you for presenting your work I wonder if you're able to look at the mechanisms that got uh activated by the implementation strategies you use so first of all hi Muhammad it's lovely to see you for those in attendance Mohammed is a very talented um student here at Northwestern um thank you s

2023-02-14 22:27

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