Applying dissemination and implementation research methods to translate a school-based asthma program

Abstract

Our school-based asthma program has reduced asthma exacerbations for youth with health disparities in the Denver metropolitan area, due partly to addressing social determinants of health, such as access to health care and medications. Dissemination and implementation (D&I) science approaches accelerate the translation of evidence-based programs into routine practice. D&I methods are being applied more commonly to improve health equity. The purpose of this publication was to give an overview of D&I research methods, using our school-based asthma program as an example. To successfully scale out our program across the state of Colorado, we are applying a D&I framework that guides the adaptation of our existing implementation approach to better meet our stakeholders' local context-the Exploration, Preparation, Implementation, Sustainment framework. In a pragmatic trial design, we will evaluate the outcomes of implementing the program across 5 Colorado regions, with attention to health equity, using a second commonly used D&I framework-Reach, Effectiveness, Adoption, Implementation, and Maintenance. Our central hypothesis is that our program will have broad and equitable reach to eligible students (primary outcome) and will reduce asthma attacks and symptoms. This D&I approach accelerates dissemination of our program and is an applicable process for translating other effective allergy/asthma programs to address asthma and allergy-related disparities.

Keywords: Asthma; EPIS; PRECIS-2; PRISM; RE-AIM; dissemination and implementation research; health disparities; social determinants of health.

Figure 1. How D&I research relates to the traditional translational research pipeline

Reproduced with permission: Brown CH et al., An Overview of Research and Evaluation Designs for Dissemination and Implementation, Ann Rev Publ Health, vol. 38, 1–22, 2017.

Figure 2. The expanded Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework

this figure depicts the RE-AIM effectiveness and implementation outcomes at the bottom of the diagram: Reach, Effectiveness, Adoption, Implementation, and Maintenance. At the top of the diagram, the constructs that commonly influence RE-AIM outcomes are depicted —these predictors are collectively described as the Pragmatic, Robust, Implementation and Sustainability (PRISM) model which serves as the determinant framework for the RE-AIM outcomes below. The PRISM contextual influences include: organizational and patient/program recipient perspectives of the intervention, characteristics of the organization and of the patient/program recipient, the implementation and sustainability infrastructure, such as the program fit with typical end-user workflows, and the external environment, such as policy incentives for the program. Reproduced with permission: Feldstein AC, Glasgow RE. A practical, robust implementation and sustainability model (PRISM) for integrating research findings into practice. Jt Comm J Qual Patient Saf. 2008;34(4):228–243.

Figure 3.. Education & Coordination to Better Control Asthma

Description of interaction among the asthma navigator/school nurse team and health care providers and social determinants of health resource agencies.

Figure 4.. Plans for Stop Asthma Attacks (SAA) and Original School-based Asthma Program (o-SBAP) overlaid on Exploration, Preparation, Implementation, Sustainment (EPIS) Framework

Visual depiction of how EPIS phases facilitate broad and equitable implementation of our o-SBAP and Stop Asthma Attacks programs

Figure 5.

Proposed study design for DECIPHeR Colorado program. This figure illustrates the proposed study design for the total 7-year study. Our NHLBI sponsor for this work has provided a 3-year planning phase – termed a “UG3 phase”, to be followed by a 4-year pragmatic trial phase, termed a “UH3 phase”. In the final year of the UG3 planning phase investigators will confirm essential data elements and operational readiness and randomize groups to one of four arms. In the four years of the UH3 pragmatic trial phase, we indicate the open cohort, parallel cluster randomized trial where intervention conditions are phased in over the first two years in the UH3 phase. The result is a 3-arm parallel Group Randomized Trial (GRT) in UH3 Year 1 and a 2-arm parallel GRT in UH3 Years 2–3. UH3 Year 4 provides an opportunity to compare those two arms in terms of choices made for maintenance. In our pragmatic trial, we will be comparing RE-AIM outcomes, with an emphasis on the comparative reach and effectiveness of delivering o-SBAP vs. SAA. Horizontal lines indicated with “beginning” or “end” represent time points within the school year for data collection for the primary implementation outcomes and primary effectiveness outcomes. In the final year of the UH3 phase, schools will choose to maintain either intervention without investigator support. The maintained interventions are termed MSAA and Mo-SBAP to indicate the distinction.