Assessing Causal Pathways and Targets of Implementation Variability for EBP use (Project ACTIVE): a study protocol

Abstract

Background Advancing causal implementation theory is critical for designing tailored implementation strategies that target specific mechanisms associated with evidence-based practice (EBP) use. This study will test the generalizability of a conceptual model that integrates organizational constructs and behavioral theory to predict clinician use of cognitive-behavioral therapy (CBT) techniques in community mental health centers. CBT is a leading psychosocial EBP for psychiatric disorders that remains underused despite substantial efforts to increase its implementation. Methods We will leverage ongoing CBT implementation efforts in two large public health systems (Philadelphia and Texas) to recruit 300 mental health clinicians and 600 of their clients across 40 organizations. Our primary implementation outcomes of interest are clinician intentions to use CBT and direct observation of clinician use of CBT. As CBT comprises discrete components that vary in complexity and acceptability, we will measure clinician use of six discrete components of CBT. After finishing their CBT training, participating clinicians will complete measures of organizational and behavior change constructs delineated in the model. Clinicians also will be observed twice via audio recording delivering CBT with a client. Within 48 h of each observation, theorized moderators of the intention-behavior gap will be collected via survey. A subset of clinicians who report high intentions to use CBT but demonstrate low use will be purposively recruited to complete semi-structured interviews assessing reasons for the intention-behavior gap. Multilevel path analysis will test the extent to which intentions and determinants of intention predict the use of each discrete CBT component. We also will test the extent to which theorized determinants of intention that include psychological, organizational, and contextual factors explain variation in intention and moderate the association between intentions and CBT use. Discussion Project ACTIVE will advance implementation theory, currently in its infancy, by testing the generalizability of a promising causal model of implementation. These results will inform the development of implementation strategies targeting modifiable factors that explain substantial variance in intention and implementation that can be applied broadly across EBPs.

A mixed-methods evaluation of organization and individual factors influencing provider intentions to use caregiver coaching in community-based early intervention

“…A recent theory of change highlights the importance of integrating both psychological and organizational theories of behavior change into implementation research when evaluating causal pathways (see Fig. 1 ) [ 26 ]. Psychological theories of behavior change can provide insight into why EI practitioners do or do not use the components of caregiver coaching and inform strategies to improve its implementation.…”

“…Leading behavior change theories posit that an individuals’ intention to perform a certain behavior is the most proximal determinant of that behavior when individuals have the ability to act on their intentions [ 27 ]. Intentions represent an individual’s motivation to perform a certain behavior and are malleable targets for implementation research [ 26 ]. The determinants of intention are attitudes (e.g., whether the practitioner “likes” or “dislikes” coaching caregivers), descriptive norms (e.g., whether the practitioner perceives that other practitioners like them use coaching), injunctive norms (e.g., whether the practitioner perceives that important others, such as supervisors, expect them to use it), and self-efficacy (e.g., whether the practitioner believes that they have the necessary skills to provide effective coaching).…”

“…Furthermore, intentions were better predictors of behavior, than attitudes, subjective norms and perceived behavioral control [ 32 ]. Therefore, evaluating an individual’s intentions to perform a certain behavior or use a specific practice facilitates the study of mechanisms that influence both intention formation and factors that facilitate or impede an individual from acting on their intention to use a practice [ 26 , 33 ]. Previous work finds substantial variability in practitioners’ intentions to implement new evidence-based practices (EBPs) and that those intentions are associated with subsequent implementation [ 4 ].…”

A review of attitude research that is specific, accurate, and comprehensive within its stated scope: responses to Aarons

“…Consistent with the results from psychology, the implementation science literature has started to document how practitioners’ attitudes can vary greatly among evidence-based practices [ 9 – 12 ]. For example, we have found that therapists’ attitudes vary towards different components of cognitive-behavioral therapy [ 10 ].…”

“…For example, we have found that therapists’ attitudes vary towards different components of cognitive-behavioral therapy [ 10 ]. Given this variability, a measure of attitudes towards “evidence-based practice” or even “cognitive behavioral therapy” would sacrifice psychometric performance, including predictive validity [ 9 – 12 ]. Depending on the specific evidence-based practice, other psychological variables also can vary [ 9 – 12 ].…”