The purpose of this study was to understand challenges that school administrators faced in their approaches to address adolescent vaping in Massachusetts middle and high schools. We analyzed open-ended comments from Massachusetts school administrators who completed a survey between November 2020 and January 2021. Further, we analyzed nine interviews with administrators (e.g., principals, vice principals, school nurses) from Massachusetts school systems (n = 6) and school-based anti-tobacco advocates (n = 3); interviews took place between May and December 2021. We found that challenges to addressing adolescent vaping included school personnel capacity, funding, and lack of mental health and counseling supports. The COVID-19 pandemic was a major barrier to conducting usual in-person vaping programs, but also reduced student vaping at school due to new social distancing practices and bathroom use policies. Successful approaches included peer-led initiatives and parental involvement, and participants discussed the importance of educating adolescents on the harms of vaping. Based on our findings, school-based anti-vaping program practitioners—such as school districts, state departments of education, or local health departments—should leverage peer-led initiatives, alternatives-to-suspension approaches, and parental involvement, to increase the potential impact of adolescent vaping prevention and treatment efforts.
Citation: Liu J, Roberts J, Reynolds MJ, Hanby E, Gundersen DA, Winickoff JP, Rees VW, Emmons KM, Tan ASL. Barriers and facilitators to address vaping in Massachusetts schools: a mixed-methods study of school-based stakeholders. Translational Behavioral Medicine. 2023;13(8):589-600. doi:10.1093/tbm/ibad012
Background: There is little guidance for conducting health equity-focused economic evaluations of evidence-based practices in resource-constrained settings, particularly with respect to staff time use. Investigators must balance the need for low-touch, non-disruptive cost data collection with the need for data on providing services to priority subpopulations.
Methods: This investigation took place within a pilot study examining the implementation of a bundled screening intervention combining screening for social determinants of health and colorectal cancer at four federally qualified health centers (FQHCs) in the Boston metropolitan area. Methods for collecting data on personnel costs for implementation and intervention activities, including passive (automatic) and active (non-automatic, requiring staff time and effort) data collection, as well as three alternate wordings for self-reporting time-use, were evaluated qualitatively using data collected through interviews with FQHC staff (including clinicians, population health staff, and community health workers) and assessments of data completeness.
Conclusion: Passively collected time use data are the least burdensome and should be pursued in research efforts when possible, but should be accompanied by qualitative assessments to ensure the data are an accurate reflection of effort. When workflows are already tracked by active data collection, these are also strong data collection methods. Self-reported time use will be most accurate when questions inquire about “typical” tasks and specific types of patients.
Citation: Levy DE, Singh D, Aschbrenner KA, Davies ME, Pelton-Cairns L, Kruse GR. Challenges and recommendations for measuring time devoted to implementation and intervention activities in health equity-focused, resource-constrained settings: a qualitative analysis. Implementation Science Communications. 2023;4(1). doi:10.1186/s43058-023-00491-7
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Racial/ethnic minorities have been disproportionately impacted by COVID-19. The effects of COVID-19 on the long-term mental health of minorities remains unclear. To evaluate differences in odds of screening positive for depression and anxiety among various racial and ethnic groups during the latter phase of the COVID-19 pandemic, we performed a cross-sectional analysis of 691,473 participants nested within the prospective smartphone-based COVID Symptom Study in the United States (U.S.) and United Kingdom (U.K). from February 23, 2021 to June 9, 2021. In the U.S. (n=57,187), compared to White participants, the multivariable odds ratios (ORs) for screening positive for depression were 1·16 (95% CI: 1·02 to 1·31) for Black, 1·23 (1·11 to 1·36) for Hispanic, and 1·15 (1·02 to 1·30) for Asian participants, and 1·34 (1·13 to 1·59) for participants reporting more than one race/other even after accounting for personal factors such as prior history of a mental health disorder, COVID-19 infection status, and surrounding lockdown stringency. Rates of screening positive for anxiety were comparable. In the U.K. (n=643,286), racial/ethnic minorities had similarly elevated rates of positive screening for depression and anxiety. These disparities were not fully explained by changes in leisure time activities. Racial/ethnic minorities bore a disproportionate mental health burden during the COVID-19 pandemic. These differences will need to be considered as health care systems transition from prioritizing infection control to mitigating long-term consequences.
Citation: Nguyen LH, Nguyen LH, Anyane-Yeboa A, Klaser K, Merino J, Drew DA, et al. The mental health burden of racial and ethnic minorities during the COVID-19 pandemic. PlosOne. 2022; 17:8. Published 2022 Aug 10. https://doi.org/10.1371/journal.pone.0271661
Background: Dissemination and implementation (D&I) research is a key factor in the uptake and use of evidence-based cancer control interventions. National Cancer Institute (NCI)–designated cancer centers are ideal settings in which to further D&I knowledge. The purpose of this study was to summarize the characteristics of NCI-funded D&I science grants in the nation’s cancer centers to understand the nature, extent, and opportunity for this key type of translational work.
Methods: We used the National Institutes of Health Research Portfolio Online Reporting Tool to identify active NCI-funded grants in D&I science at NCI clinical cancer centers (n = 13) and comprehensive cancer centers (n = 51) as well as their academic affiliates. Active projects were eligible for inclusion if they 1) were awarded directly to an NCI cancer center or an academic or research affiliate, and 2) identified D&I content in the abstract. Portfolio data were collected in February 2021.
Results: We identified 104 active NCI-funded D&I research or training grants across the 64 cancer centers; 57.8% of cancer centers had at least 1 NCI-funded D&I grant. Most awards (71.1%) were for research grants. Training grants constituted 29.1% of D&I-focused grants. Overall, 50.0% of grants (n = 52) concentrated on specific cancers. Almost two-thirds of grants (n = 68, 65.4%) had a stated health equity focus.
Conclusions: More than one-half of NCI-designated cancer centers have active funding in D&I science, reflecting a substantial investment by NCI. There remains considerable room for further development, which would further support NCI’s translational mission.
Citation: Mueller NM, Hsieh A, Ramanadhan S, Lee RM, Emmons KM. The prevalence of dissemination and implementation research and training grants at National Cancer Institute–Designated Cancer Centers. JNCI Cancer Spectru. 2022; 6:1. Published 2021 Dec 15. https://doi.org/10.1093/jncics/pkab092
Background: More than half of cancers could be prevented by employing evidence-based interventions (EBIs), including prevention interventions targeting nutrition, physical activity, and tobacco. Federally qualified health centers (FQHCs) are the primary source of patient care for over 30 million Americans — making them an optimal setting for ensuring evidence-based prevention that advances health equity. The aims of this study are to (1) determine the degree to which primary cancer prevention EBIs are being implemented within Massachusetts FQHCs and (2) describe how these EBIs are implemented internally and via community partnerships.
Methods: We used an explanatory sequential mixed methods design to assess the implementation of cancer prevention EBIs. First, we collected 34 quantitative surveys from staff at 16 FQHCs across Massachusetts to determine the frequency of EBI implementation. We followed up with 12 qualitative one-on-one interviews among a sample of staff to understand how the EBIs selected on the survey were implemented. Exploration of contextual influences on implementation and use of partnerships was guided by the Consolidated Framework for Implementation Research (CFIR). Quantitative data were summarized descriptively, and qualitative analyses used reflexive, thematic approaches, beginning deductively with codes from CFIR, then inductively coding additional categories.
Results: All FQHCs indicated they offered clinic-based tobacco interventions, such as clinician-delivered screening practices and prescription of tobacco cessation medications. Quitline interventions and some diet/physical activity EBIs were available at all FQHCs, but staff perceptions of penetration were low. Only 38% of FQHCs offered group tobacco cessation counseling and 63% referred patients to mobile phone-based cessation interventions. We found multilevel factors influenced implementation across intervention types — including the complexity of intervention trainings, available time and staffing, motivation of clinicians, funding, and external policies and incentives. While partnerships were described as valuable, only one FQHC reported using clinical-community linkages for primary cancer prevention EBIs.
Conclusions: Adoption of primary prevention EBIs in Massachusetts FQHCs is relatively high, but stable staffing and funding are required to successfully reach all eligible patients. FQHC staff are enthusiastic about the potential of community partnerships to foster improved implementation—providing training and support to build these relationships will be key to fulfilling that promise.
Citation: Lee RM, Daly JG, Mallick K, Ramanadhan S, Torres CH, Hayes CR, Manuel A, Nalls R, Emmons KM. Implementation of evidence-based primary cancer prevention interventions in MA community health centers: an explanatory sequential mixed methods study. Implementation Science Communications. 2023;4(1). doi:10.1186/s43058-023-00483-7
Introduction: Access to COVID-19 testing has been inequitable and misaligned with community need. However, community health centers have played a critical role in addressing the COVID-19 testing needs of historically disadvantaged communities. The aim of this paper is to explore the perceptions of COVID-19 testing barriers in six Massachusetts communities that are predominantly low income and describe how these findings were used to build tailored clinical-community strategies to addressing testing inequities.
Methods: Between November 2020 and February 2021, we conducted 84 semi-structured qualitative interviews with 107 community health center staff, community partners, and residents. Resident interviews were conducted in English, Spanish, Vietnamese, and Arabic. We used a 2-phase framework analysis to analyze the data, including deductive coding to facilitate rapid analysis for action and an in-depth thematic analysis applying the Social Ecological Model.
Results: Through the rapid needs assessment, we developed cross-site suggestions to improve testing implementation and communications, as well as community-specific recommendations (e.g., locations for mobile testing sites and local communication channels). Upstream barriers identified in the thematic analysis included accessibility of state-run testing sites, weak social safety nets, and lack of testing supplies and staffing that contributed to long wait times. These factors hindered residents’ abilities to get tested, which was further exacerbated by individual fears surrounding the testing process and limited knowledge on testing availability.
Discussion: Our rapid, qualitative approach created the foundation for implementing strategies that reached underserved populations at the peak of the COVID-19 pandemic in winter 2021. We explored perceptions of testing barriers and created actionable summaries within 1-2 months of data collection. Partnering community health centers in Massachusetts were able to use these data to respond to the local needs of each community. This study underscores the substantial impact of upstream, structural disparities on the individual experience of COVID-19 and demonstrates the utility of shifting from a typical years’ long research translation process to a rapid approach of using data for action.
Citation: Lee RM, Handunge VL, Augenbraun SL, et al. Addressing COVID-19 Testing Inequities Among Underserved Populations in Massachusetts: A Rapid Qualitative Exploration of Health Center Staff, Partner, and Resident Perceptions. Front Public Health. 2022;10:838544. Published 2022 Mar 24. doi:10.3389/fpubh.2022.838544
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Background: Community Health Centers (CHCs) are a critical source of care for low-income and non-privately insured populations. During the pandemic, CHCs have leveraged their infrastructure and role as a trusted source of care to engage the communities they serve in COVID-19 testing.
Methods: To directly address the impact that COVID-19 has had on historically marginalized populations in Massachusetts, we designed a study of community-engaged COVID-19 testing expansion: (1) leveraging existing partnerships to accelerate COVID-19 testing and rapidly disseminate effective implementation strategies; (2) incorporating efforts to address key barriers to testing participation in communities at increased risk for COVID-19; (3) further developing partnerships between communities and CHCs to address testing access and disparities; (4) grounding the study in the development of a shared ethical framework for advancing equity in situations of scarcity; and (5) developing mechanisms for communication and science translation to support community outreach. We use a controlled interrupted time series design, comparing number of COVID-19 tests overall and among people identified as members of high-risk groups served by intervention CHCs compared with six matched control CHCs in Massachusetts, followed by a stepped wedge design to pilot test strategies for tailored outreach by CHCs.
Conclusions: Here, we describe a community-partnered strategy to accelerate COVID-19 testing in historically marginalized populations that provides ongoing resources to CHCs for addressing testing needs in their communities. The study aligns with principles of community-engaged research including shared leadership, adequate resources for community partners, and the flexibility to respond to changing needs over time.
Citation: Kruse GR, Pelton-Cairns L, Taveras E, Dargon-Hart S, Gundersen G, Lee RM, Bierer BE, Lawlor E, LaRocque R, Marcus JM, Davies ME, Emmons K, the RADx-MA Research Partnership. Implementing expanded COVID-19 testing in Massachusetts community health centers through community partnerships: Protocol for an interrupted time series and stepped wedge study design. Contemporary Clinical Trials. 2022; 118:106783. Published 2022 July. https://doi.org/10.1016/j.cct.2022.106783.
Gaps in the implementation of effective interventions impact nearly all cancer prevention and control strategies in the US including Massachusetts. To close these implementation gaps, evidence-based interventions must be rapidly and equitably implemented in settings serving racially, ethnically, socioeconomically, and geographically diverse populations. This paper provides a brief overview of The Implementation Science Center for Cancer Control Equity (ISCCCE) and describes how we have operationalized our commitment to a robust community-engaged center that aims to close these gaps. We describe how ISCCCE is organized and how the principles of community-engaged research are embedded across the center. Principles of community engagement have been operationalized across all components of ISCCCE. We have intentionally integrated these principles throughout all structures and processes and have developed evaluation strategies to assess whether the quality of our partnerships reflects the principles. ISCCCE is a comprehensive community-engaged infrastructure for studying efficient, pragmatic, and equity-focused implementation and adaptation strategies for cancer prevention in historically and currently disadvantaged communities with built-in methods to evaluate the quality of community engagement. This engaged research center is designed to maximize the impact and relevance of implementation research on cancer control in community health centers.
Citation: Kruse GR, Lee RM, Aschbrenner KA, Daly JG, Dargon-Hart S, Davies ME, Gundersen DA, Pelton-Cairns L, Winickoff J, Taveras E, Emmons KM, and The ISCCCE Consortium. Embedding community-engaged research principles in implementation science: The implementation science center for cancer control equity. Journal of Clinical and Translational Science. 2023;7(1):e82. doi:10.1017/cts.2023.32
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Background: In 2019–2020, with National Cancer Institute funding, seven implementation laboratory (I-Lab) partnerships between scientists and stakeholders in ‘real-world’ settings working to implement evidence-based interventions were developed within the Implementation Science Centers in Cancer Control (ISC3) consortium. This paper describes and compares approaches to the initial development of seven I-Labs in order to gain an understanding of the development of research partnerships representing various implementation science designs.
Methods: In April-June 2021, members of the ISC3 Implementation Laboratories workgroup interviewed research teams involved in I-Lab development in each center. This cross-sectional study used semi-structured interviews and case-study-based methods to collect and analyze data about I-Lab designs and activities. Interview notes were analyzed to identify a set of comparable domains across sites. These domains served as the framework for seven case descriptions summarizing design decisions and partnership elements across sites.
Conclusions: The development of the ISC3 implementation laboratories, which represented a variety of research partnership designs, offers the opportunity to advance understanding of how researchers developed and built partnerships to effectively engage stakeholders throughout the cancer control research lifecycle. In future years, we will be able to share lessons learned for the development and sustainment of implementation laboratories.
Citation: Kruse G, Hale E, Bekelman JE, et al. Creating research-ready partnerships: the initial development of seven implementation laboratories to advance cancer control. BMC Health Services Research. 2023;23(1). Published February 21, 2023. https://doi.org/10.1186/s12913-023-09128-w
Background: Bundling is combining individual interventions to meet quality metrics. Bundling offers of cancer screening with screening for social determinants of health (SDOH) may enable health centers to assist patients with social risks and yield efficiencies.
Methods: Outreach to 50–75-year-olds overdue for CRC screening to offer FIT with SDOH screening. The implementation strategy used facilitation and training for data monitoring and reporting.
Key Results: FQHCs tailored implementation processes to their infrastructure, workflows, and staffing and prioritized different groups for outreach. Two FQHCs used population health outreach, and two integrated FIT-SDOH within established programs, such as pre-visit planning. Of 34,588 patients overdue for CRC screening, 54% were female; 20% Black, 11% Latino, 10% Asian, and 47% white; 32% had Medicaid, 16% Medicare, 32% private insurance, and 11% uninsured. Odds of CRC screening completion in implementation “steps” compared to controls were higher overall and among groups prioritized for outreach (overall: adjusted odds ratio (aOR) 2.41, p = 0.005; prioritized: aOR 2.88, p = 0.002). Odds of SDOH screening did not differ across “steps.”
Citation: Kruse GR, Percac-Lima S, Barber-Dubois M. et al. Bundling Colorectal Cancer Screening Outreach with Screening for Social Risk in Federally Qualified Health Centers: A Stepped-Wedge Implementation-Effectiveness Study. J GEN INTERN MED 39, 1188–1195 (2024). https://doi.org/10.1007/s11606-024-08654-5
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