Professor of Public Health Policy and Management
Director of Global Center for Implementation Science
Dr. Shelley is a tenured Professor and Vice Chair for Research in the Department of Public Health Policy and Management and the founding Director of the Global Center for Implementation Science and Practice at the NYU School of Global Public Health. She conducts translational, population-based, and policy-relevant research that aims to accelerate dissemination and implementation of tobacco use treatment in safety net health care delivery systems and implementation of tobacco control policies. This research has been funded by the National Cancer Institute (NCI), National Institute of Drug Abuse, National Heart, Lung, Blood Institute, the Agency for Healthcare Research and Quality and the New York State Department of Health.
Dr. Shelley’s implementation research focuses on building the evidence for effective theory-driven strategies that target barriers to implementation and sustainability of evidence-based tobacco use treatment in primary care settings in the U.S and Viet Nam. Her research is also addressing the growing dual burden of noncommunicable and communicable diseases in LMICs and, specifically, the health impact on people living with HIV/AIDS. With funding from the NCI, Dr. Shelley is conducting a randomized controlled trial comparing the effectiveness of behavioral interventions and pharmacotherapy to improve cessation outcomes among people living with HIV/AIDs who use tobacco, and simultaneously, answering questions about the feasibility and effectiveness of implementation strategies to improve adoption of tobacco use treatment in HIV care settings in Viet Nam. An example of her policy research includes a recently completed NCI-funded study that evaluated the impact of the US federally mandated smoke free public housing policy on exposure to secondhand smoke and explored the implementation process to identify strategies with the potential to improve the process and maximize public health impact.
BS, University of Pennsylvania, PAMD, Mount Sinai School of Medicine, NYMPH, Health Policy and Management, Columbia University's Mailman School of Public Health, NY
Health Systems StrengtheningImplementation scienceTobacco CessationTobacco Policy
Development of a homelessness risk screening tool for emergency department patients
Effectiveness of a Multicomponent Strategy for Implementing Guidelines for Treating Tobacco Use in Vietnam Commune Health Centers
Leveraging technology to address unhealthy drug use in primary care: Effectiveness of the Substance use Screening and Intervention Tool (SUSIT)
Social relationships, homelessness, and substance use among emergency department patientsJurewicz, A., Padgett, D. K., Ran, Z., Castelblanco, D. G., McCormack, R. P., Gelberg, L., Shelley, D., & Doran, K. M.
Journal titleSubstance Abuse
Page(s)573-580AbstractBackground: Emergency department (ED) patients commonly experience both substance use and homelessness, and social relationships impact each in varied ways not fully captured by existing quantitative research. This qualitative study examines how social relationships can precipitate or ameliorate homelessness and the connection (if any) between substance use and social relationships among ED patients experiencing homelessness. Methods: As part of a broader study to develop ED-based homelessness prevention interventions, we conducted in-depth interviews with 25 ED patients who used alcohol or drugs and had recently become homeless. We asked patients about the relationship between their substance use and homelessness. Interviews were recorded, transcribed, and coded line-by-line by investigators. Final codes formed the basis for thematic analysis through consensus discussions. Results: Social relationships emerged as focal points for understanding the four major themes related to the intersection of homelessness and substance use: (1) Substance use can create strain in relationships; (2) Help is there until it’s not; (3) Social relationships can create challenges contributing to substance use; and (4) Reciprocal relationship of substance use and isolation. Sub-themes were also identified and described. Conclusions: The association between substance use and homelessness is multifaceted and social relationships are a complex factor linking the two. Social relationships are often critical for homelessness prevention, but they are impacted by and reciprocally affect substance use. ED-based substance use interventions should consider the high prevalence of homelessness and the impact of social relationships on the interaction between homelessness and substance use.
The Effect of Floor Height on Secondhand Smoke Transfer in Multiunit HousingGill, E., Anastasiou, E., Tovar, A., Shelley, D., Rule, A., Chen, R., Thorpe, L. E., & Gordon, T.
Journal titleInternational journal of environmental research and public health
Issue7AbstractSecondhand smoke (SHS) exposure remains a major public health concern in the United States. Homes have become the primary source of SHS exposure, with elevated risks for residents of multiunit housing. Though this differential risk is well-documented, little is known about whether SHS exposure varies by floor height. The aim of this study was to examine whether SHS accumulates in higher floors of multiunit housing. Using validated passive nicotine sampling monitors, we sampled air nicotine concentrations on multiple floors of 21 high-rise (>15 floors) buildings in New York City. Within the buildings, measurements were collected in three locations: non-smoking individual apartments, hallways and stairwells. Measurements were collected in two winter and two summer waves to account for potential seasonality effects. We analyzed the percent of filters with detectable nicotine and quantified nicotine concentration (µg/m3). Higher floor levels were positively associated with both airborne nicotine measures, with some variation by location and season observed. In winter, the trends were statistically significant in apartments (floors ≤7: 0.022 µg/m3; floors 8–14: 0.026 µg/m3; floors ≥15: 0.029 µg/m3; p = 0.011) and stairwells (floors ≤7: 0.18 µg/m3; floors 8–14: 0.19 µg/m3; floors ≥15: 0.59 µg/m3; p = 0.006). These findings can inform interventions to mitigate the SHS exposure of residents in multiunit housing.
A qualitative study of high-performing primary care practices during the COVID-19 pandemic
A taxonomy for external support for practice transformation
Adaptation and assessment of a text messaging smoking cessation intervention in Vietnam: Pilot randomized controlled trialJiang, N., Nguyen, N., Siman, N., Cleland, C. M., Nguyen, T., Doan, H. T., Abroms, L. C., & Shelley, D. R.
Journal titleJMIR mHealth and uHealth
Issue10AbstractBackground: Text message (ie, short message service, SMS) smoking cessation interventions have demonstrated efficacy in high-income countries but are less well studied in low- and middle-income countries, including Vietnam. Objective: The goal of the research is to assess the feasibility, acceptability, and preliminary efficacy of a fully automated bidirectional SMS cessation intervention adapted for Vietnamese smokers. Methods: The study was conducted in 3 phases. In phase 1, we adapted the SMS library from US-based SMS cessation programs (ie, SmokefreeTXT and Text2Quit). The adaptation process consisted of 7 focus groups with 58 smokers to provide data on culturally relevant patterns of tobacco use and assess message preferences. In phase 2, we conducted a single-arm pilot test of the SMS intervention with 40 smokers followed by in-depth interviews with 10 participants to inform additional changes to the SMS library. In phase 3, we conducted a 2-arm pilot randomized controlled trial (RCT) with 100 smokers. Participants received either the SMS program (intervention; n=50) or weekly text assessment on smoking status (control; n=50). The 6-week SMS program consisted of a 2-week prequit period and a 4-week postquit period. Participants received 2 to 4 automated messages per day. The main outcomes were engagement and acceptability which were assessed at 6 weeks (end of intervention). We assessed biochemically confirmed smoking abstinence at 6 weeks and 12 weeks. Postintervention in-depth interviews explored user experiences among a random sample of 16 participants in the intervention arm. Results: Participants in both arms reported high levels of engagement and acceptability. Participants reported using the program for an average of 36.4 (SD 3.4) days for the intervention arm and 36.0 (SD 3.9) days for the control arm. Four of the 50 participants in the intervention arm (8%) reset the quit date and 19 (38%) texted the keyword TIPS. The majority of participants in both arms reported that they always or usually read the text messages. Compared to the control arm, a higher proportion of participants in the intervention arm reported being satisfied with the program (98% [49/50] vs 82% [41/50]). Biochemically verified abstinence was higher in the intervention arm at 6 weeks (20% [10/50] vs 2% [1/50]; P=.01), but the effect was not significant at 12 weeks (12% [6/50] vs 6% [3/50]; P=.49). In-depth interviews conducted after the RCT suggested additional modifications to enhance the program including tailoring the timing of messages, adding more opportunities to interact with the program, and placing a greater emphasis on messages that described the harms of smoking. Conclusions: The study supported the feasibility and acceptability of an SMS program adapted for Vietnamese smokers. Future studies need to assess whether, with additional modifications, the program is associated with prolonged abstinence.
Barriers to engagement in implementation science research: A national surveyStevens, E. R., Shelley, D., & Boden-Albala, B.
Journal titleTranslational Behavioral Medicine
Page(s)408-418AbstractLow levels of engagement in implementation science (IS) among health researchers is a multifaceted issue. With the aim of guiding efforts to increase engagement in IS research, we sought to identify barriers to engagement in IS within the health research community. We performed an online survey of health researchers in the United States in 2018. Basic science researchers were excluded from the sample. IS engagement was measured by self-reported conduct of or collaboration on an IS study in the past 5 years. Potential barriers tested were (a) knowledge and awareness of IS, (b) attitudes about IS research, (c) career benefits of IS, (d) research community support, and (e) research leadership support. We performed simple logistic regressions and tested multivariable logistic regression models of researcher characteristics and potential barriers as predictors of IS engagement. Of the 1,767 health researchers, 49.7% indicated they engaged in an implementation study. Being able to define IS (aOR 3.42, 95%CI 2.68-4.36, p <. 001) and having attended IS training (aOR 3.77, 95%CI 2.96-4.81, p <. 001) were associated with engaging in IS research. Among other potential barriers tested, perceptions that engaging in IS would not be good for their career (aOR 0.29, 95%CI 0.2-0.41, p <. 001) was strongly associated with decreased engagement in IS research. Efforts to increase researcher familiarity with IS methods and foster support for IS within research communities, along with decreasing barriers to funding and publishing, are likely to be most effective for increasing engagement in IS research.
Cost Analysis of Community-Based Smoking Cessation Services in Vietnam: A Cluster-Randomized TrialQuynh Mai, V., Van Minh, H., Truong Nam, N., Thao Anh, H., Minh Van, N., Thi Trang, N., & Shelley, D.
Journal titleHealth Services Insights
Volume14AbstractThe study aimed to estimate the cost for developing and implementing 2 smoking cessation service delivery models that were evaluated in a 2-arm cluster randomized trial in Commune Health Centers (CHCs) in Vietnam. In the first model (4As) CHC providers were trained to ask about tobacco use, advise smokers to quit, assess readiness to quit, and assist with brief counseling. The second model included the 4As plus a referral to Village Health Workers (VHWs) who were trained to provide multisession home-based counseling (4As + R). An activity-based ingredients (ABC-I) costing approach with a healthcare provider perspective was applied to collect the costs for each intervention model. Opportunity costs were excluded. Costs during preparation and implementation phase were estimated. Sensitivity analysis of the cost per smoker with the included intervention’ activities were conducted. The cost per facility-based counseling session ranged from USD 9 to USD 11. Cost per home-based counseling session at 4As + R model was USD 4. The non-delivery cost attributed to supportive activities (eg, Monitoring, Logistic, Research, General training) was USD 107 per counseling session. Cost per smoker ranged from USD 6 to USD 451. The study analyzed and compared cost of implementing and scaling community-based smoking cessation service models in Vietnam.
E-cigarette use and beliefs among adult smokers with substance use disordersEl-Shahawy, O., Schatz, D., Sherman, S., Shelley, D., Lee, J. D., & Tofighi, B.
Journal titleAddictive Behaviors Reports
Volume13AbstractBackground: We explored characteristics and beliefs associated with e-cigarette use patterns among cigarette smokers requiring inpatient detoxification for opioid and/or alcohol use disorder(s). Methods: Adult cigarette smokers (≥18 years), admitted to inpatient detoxification for alcohol and/or opioid use disorder(s) in a safety-net tertiary referral center in New York City were surveyed in 2015 (n = 158). Descriptive statistics (proportions) were used to assess for demographic, clinical diagnosis, cigarette smoking patterns (exclusive and dual use of e-cigarettes). Chi-square, t-test statistics, and logistic regression models were used. Results: Among our sample of combustible cigarette users, 13.9% (n = 22) reported dual use with electronic cigarettes. Dual use did not differ by demographic or clinical variables. Compared to exclusive smokers, dual users were more likely to have tried to quit in the past year (Adjusted Odds ratio = 8.59; CI: 2.58, 28.35; p < 0.001). Dual smokers had significantly higher mean ratings perceiving that e-cigarettes can help people quit smoking compared to exclusive smokers (M = 3.7, SD= ±1.4 vs. M = 2.7, SD= ±1.5, p = 0.002) respectively. Dual users also preferred e-cigarettes over nicotine patches /gum for quitting (M = 3.7, SD= ±1.7 vs. M = 2.6, SD= ±1.6, p = 0.005). Conclusions: E-cigarette use seems to be appealing to a small proportion of cigarette smokers with SUD. Although, dual smokers seem to use e-cigarettes for its cessation premise, they don't appear to be actively seeking to quit. E-cigarettes may offer a more effective method for harm reduction, further evaluation of incorporating it within smoking cessation protocols among patients in addiction treatment is needed.
Effectiveness and Reach of the Primary Palliative Care for Emergency Medicine (PRIM-ER) Pilot Study: a Qualitative Analysis
Effectiveness of an integrated engagement support system to facilitate patient use of digital diabetes prevention programs: Protocol for a randomized controlled trialLawrence, K., Rodriguez, D. V., Feldthouse, D. M., Shelley, D., Yu, J. L., Belli, H. M., Gonzalez, J., Tasneem, S., Fontaine, J., Groom, L. L., Luu, S., Wu, Y., McTigue, K. M., Rockette-Wagner, B., & Mann, D. M.
Journal titleJMIR Research Protocols
Issue2AbstractBackground: Digital diabetes prevention programs (dDPPs) are effective behavior change tools to prevent disease progression in patients at risk for diabetes. At present, these programs are poorly integrated into existing health information technology infrastructure and clinical workflows, resulting in barriers to provider-level knowledge of, interaction with, and support of patients who use dDPPs. Tools that can facilitate patient-provider interaction around dDPPs may contribute to improved patient engagement and adherence to these programs and improved health outcomes. Objective: This study aims to use a rigorous, user-centered design (UCD) methodology to develop a theory-driven system that supports patient engagement with dDPPs and their primary care providers with their care. Methods: This study will be conducted in 3 phases. In phase 1, we will use systematic UCD, Agile software development, and qualitative research methods to identify key user (patients, providers, clinical staff, digital health technologists, and content experts) requirements, constraints, and prioritization of high-impact features to design, develop, and refine a viable intervention prototype for the engagement system. In phase 2, we will conduct a single-arm feasibility pilot of the engagement system among patients with prediabetes and their primary care providers. In phase 3, we will conduct a 2-arm randomized controlled trial using the engagement system. Primary outcomes will be weight, BMI, and A1c at 6 and 12 months. Secondary outcomes will be patient engagement (use and activity) in the dDPP. The mediator variables (self-efficacy, digital health literacy, and patient-provider relationship) will be measured. Results: The project was initiated in 2018 and funded in September 2019. Enrollment and data collection for phase 1 began in September 2019 under an Institutional Review Board quality improvement waiver granted in July 2019. As of December 2020, 27 patients have been enrolled and first results are expected to be submitted for publication in early 2021. The study received Institutional Review Board approval for phases 2 and 3 in December 2020, and phase 2 enrollment is expected to begin in early 2021. Conclusions: Our findings will provide guidance for the design and development of technology to integrate dDPP platforms into existing clinical workflows. This will facilitate patient engagement in digital behavior change interventions and provider engagement in patients’ use of dDPPs. Integrated clinical tools that can facilitate patient-provider interaction around dDPPs may contribute to improved patient adherence to these programs and improved health outcomes by addressing barriers faced by both patients and providers. Further evaluation with pilot testing and a clinical trial will assess the effectiveness and implementation of these tools.
Health-Related Social Needs Among Emergency Department Patients with HIVGerber, E., Gelberg, L., Cowan, E., Mijanovich, T., Shelley, D., Gulati, R., Wittman, I., & Doran, K. M.
Journal titleAIDS and Behavior
Page(s)1968-1974AbstractLittle research has examined the health-related social needs of emergency department (ED) patients who have HIV. We surveyed a random sample of public hospital ED patients and compared the social needs of patients with and without HIV. Social needs were high among all ED patients, but patients with HIV reported significantly higher levels of food insecurity (65.0% vs. 50.3%, p = 0.01) and homelessness or living doubled up (33.8% vs. 21.0%, p < 0.01) than other patients. Our findings suggest the importance of assessing social needs in ED-based interventions for patients with HIV.
Implementation of a multi-level community-clinical linkage intervention to improve glycemic control among south Asian patients with uncontrolled diabetes: study protocol of the DREAM initiativeLim, S., Wyatt, L. C., Mammen, S., Zanowiak, J. M., Mohaimin, S., Troxel, A. B., Lindau, S. T., Gold, H. T., Shelley, D., Trinh-Shevrin, C., & Islam, N. S.
Journal titleBMC Endocrine Disorders
Issue1AbstractBackground: A number of studies have identified patient-, provider-, and community-level barriers to effective diabetes management among South Asian Americans, who have a high prevalence of type 2 diabetes. However, no multi-level, integrated community health worker (CHW) models leveraging health information technology (HIT) have been developed to mitigate disease among this population. This paper describes the protocol for a multi-level, community-clinical linkage intervention to improve glycemic control among South Asians with uncontrolled diabetes. Methods: The study includes three components: 1) building the capacity of primary care practices (PCPs) to utilize electronic health record (EHR) registries to identify patients with uncontrolled diabetes; 2) delivery of a culturally- and linguistically-adapted CHW intervention to improve diabetes self-management; and 3) HIT-enabled linkage to culturally-relevant community resources. The CHW intervention component includes a randomized controlled trial consisting of group education sessions on diabetes management, physical activity, and diet/nutrition. South Asian individuals with type 2 diabetes are recruited from 20 PCPs throughout NYC and randomized at the individual level within each PCP site. A total of 886 individuals will be randomized into treatment or control groups; EHR data collection occurs at screening, 6-, 12-, and 18-month. We hypothesize that individuals receiving the multi-level diabetes management intervention will be 15% more likely than the control group to achieve ≥0.5% point reduction in hemoglobin A1c (HbA1c) at 6-months. Secondary outcomes include change in weight, body mass index, and LDL cholesterol; the increased use of community and social services; and increased health self-efficacy. Additionally, a cost-effectiveness analysis will focus on implementation and healthcare utilization costs to determine the incremental cost per person achieving an HbA1c change of ≥0.5%. Discussion: Final outcomes will provide evidence regarding the effectiveness of a multi-level, integrated EHR-CHW intervention, implemented in small PCP settings to promote diabetes control among an underserved South Asian population. The study leverages multisectoral partnerships, including the local health department, a healthcare payer, and EHR vendors. Study findings will have important implications for the translation of integrated evidence-based strategies to other minority communities and in under-resourced primary care settings. Trial registration: This study was registered with clinicaltrials.gov: NCT03333044 on November 6, 2017.
Implementation Science to Improve Tobacco Cessation Services in Oncology Care
Implementation, interrupted: Identifying and leveraging factors that sustain after a programme interruption
Implementing the federal smoke-free public housing policy in New York City: Understanding challenges and opportunities for improving policy impactJiang, N., Gill, E., Thorpe, L. E., Rogers, E. S., De Leon, C., Anastasiou, E., Kaplan, S. A., & Shelley, D.
Journal titleInternational journal of environmental research and public health
Issue23AbstractIn 2018, the U.S. Department of Housing and Urban Development required public housing authorities to implement a smoke-free housing (SFH) policy that included individual apartments. We analyzed the policy implementation process in the New York City Public Housing Authority (NYCHA). From June–November 2019, we conducted 9 focus groups with 64 NYCHA residents (smokers and nonsmokers), 8 key informant interviews with NYCHA staff and resident association leaders, and repeated surveys with a cohort of 130 nonsmoking households pre-and 12-month post policy. One year post policy implementation, participants reported widespread smoking violations and multi-level factors impeding policy implementation. These included the shared belief among residents and staff that the policy overreached by “telling people what to do in their own apartments”. This hindered compliance and enforcement efforts. Inconsistent enforcement of illegal marijuana use, staff smoking violations, and a lack of accountability for other pressing housing issues created the perception that smokers were being unfairly targeted, as did the lack of smoking cessation resources. Resident support for the policy remained unchanged but satisfaction with enforcement declined (60.1% vs. 48.8%, p = 0.047). We identified multilevel contextual factors that are influencing SFH policy implementation. Findings can inform the design of strategies to optimize policy implementation.
Rapid Transition to Telehealth and the Digital Divide: Implications for Primary Care Access and Equity in a Post-COVID EraChang, J. E., Lai, A. Y., Gupta, A., Nguyen, A. M., Berry, C. A., & Shelley, D. R.
Journal titleMilbank Quarterly
Page(s)340-368AbstractPolicy Points Telehealth has many potential advantages during an infectious disease outbreak such as the COVID-19 pandemic, and the COVID-19 pandemic has accelerated the shift to telehealth as a prominent care delivery mode. Not all health care providers and patients are equally ready to take part in the telehealth revolution, which raises concerns for health equity during and after the COVID-19 pandemic. Without proactive efforts to address both patient- and provider-related digital barriers associated with socioeconomic status, the wide-scale implementation of telehealth amid COVID-19 may reinforce disparities in health access in already marginalized and underserved communities. To ensure greater telehealth equity, policy changes should address barriers faced overwhelmingly by marginalized patient populations and those who serve them. Context: The COVID-19 pandemic has catalyzed fundamental shifts across the US health care delivery system, including a rapid transition to telehealth. Telehealth has many potential advantages, including maintaining critical access to care while keeping both patients and providers safe from unnecessary exposure to the coronavirus. However, not all health care providers and patients are equally ready to take part in this digital revolution, which raises concerns for health equity during and after the COVID-19 pandemic. Methods: The study analyzed data about small primary care practices’ telehealth use and barriers to telehealth use collected from rapid-response surveys administered by the New York City Department of Health and Mental Hygiene's Bureau of Equitable Health Systems and New York University from mid-April through mid-June 2020 as part of the city's efforts to understand how primary care practices were responding to the COVID-19 pandemic following New York State's stay-at-home order on March 22. We focused on small primary care practices because they represent 40% of primary care providers and are disproportionately located in low-income, minority or immigrant areas that were more severely impacted by COVID-19. To examine whether telehealth use and barriers differed based on the socioeconomic characteristics of the communities served by these practices, we used the Centers for Disease Control and Prevention Social Vulnerability Index (SVI) to stratify respondents as being in high-SVI or low-SVI areas. We then characterized respondents’ telehealth use and barriers to adoption by using means and proportions with 95% confidence intervals. In addition to a primary analysis using pooled data across the five waves of the survey, we performed sensitivity analyses using data from respondents who only took one survey, first wave only, and the last two waves only. Findings: While all providers rapidly shifted to telehealth, there were differences based on community characteristics in both the primary mode of telehealth used and the types of barriers experienced by providers. Providers in high-SVI areas were almost twice as likely as providers in low-SVI areas to use telephones as their primary telehealth modality (41.7% vs 23.8%; P <.001). The opposite was true for video, which was used as the primary telehealth modality by 18.7% of providers in high-SVI areas and 33.7% of providers in low-SVI areas (P <0.001). Providers in high-SVI areas also faced more patient-related barriers and fewer provider-related barriers than those in low-SVI areas. Conclusions: Between April and June 2020, telehealth became a prominent mode of primary care delivery in New York City. However, the transition to telehealth did not unfold in the same manner across communities. To ensure greater telehealth equity, policy changes should address barriers faced overwhelmingly by marginalized patient populations and those who serve them.
Sustainability of Tobacco Treatment Programs in the Cancer Center Cessation InitiativeFailed generating bibliography.Abstract
Journal titleJournal of the National Comprehensive Cancer Network : JNCCN
Page(s)S16-S20AbstractThe NCI's Cancer Center Cessation Initiative (C3I) has a specific objective of helping cancer centers develop and implement sustainable programs to routinely address tobacco cessation with patients. Sustaining tobacco treatment programs requires the maintenance of (1) core program components, (2) ongoing implementation strategies, and (3) program outcomes evaluation. NCI funding of C3I included a commitment of resources toward sustainability. This article presents case studies to illustrate key strategies in developing sustainability capacity across 4 C3I-funded sites. Case studies are organized according to the domains of sustainability capacity defined in the Clinical Sustainability Assessment Tool (CSAT). We also describe the C3I Sustainability Working Group agenda to make scientific and practical contributions in 3 areas: (1) demonstrating the value of tobacco use treatment in cancer care, (2) identifying implementation strategies to support sustainability, and (3) providing evidence to inform policy changes that support the prioritization and financing of tobacco use treatment. By advancing this agenda, the Sustainability Working Group can play an active role in advancing and disseminating knowledge for tobacco treatment program sustainability to assist cancer care organizations in addressing tobacco use by patients with cancer within and beyond C3I.
Telephone vs. video visits during COVID-19: Safety-net provider perspectives
A cross-cutting workforce solution for implementing community–clinical linkage modelsIslam, N., Rogers, E. S., Schoenthaler, A., Thorpe, L. E., & Shelley, D.
Journal titleAmerican journal of public health
A qualitative assessment of factors influencing implementation and sustainability of evidence-based tobacco use treatment in Vietnam health centersVanDevanter, N., Vu, M., Nguyen, A., Nguyen, T., Van Minh, H., Nguyen, N. T., & Shelley, D. R.
Journal titleImplementation Science
Issue1AbstractBackground: Effective strategies are needed to increase implementation and sustainability of evidence-based tobacco dependence treatment (TDT) in public health systems in low- and middle-income countries (LMICs). Our two-arm cluster randomized controlled trial (VQuit) found that a multicomponent implementation strategy was effective in increasing provider adherence to TDT guidelines in commune health center (CHCs) in Vietnam. In this paper, we present findings from a post-implementation qualitative assessment of factors influencing effective implementation and program sustainability. Methods: We conducted semi-structured qualitative interviews (n = 52) with 13 CHC medical directors (i.e., physicians), 25 CHC health care providers (e.g., nurses), and 14 village health workers (VHWs) in 13 study sites. Interviews were transcribed and translated into English. Two qualitative researchers used both deductive (guided by the Consolidated Framework for Implementation Research) and inductive approaches to analysis. Results: Facilitators of effective implementing of TDT included training and point-of-service tools (e.g., desktop chart with prompts for offering brief counseling) that increased knowledge and self-efficacy, patient demand for TDT, and a referral system, available in arm 2, which reduced the provider burden by shifting more intensive cessation counseling to a trained VHW. The primary challenges to sustainability were competing priorities that are driven by the Ministry of Health and may result in fewer resources for TDT compared with other health programs. However, providers and VHWs suggested several options for adapting the intervention and implementation strategies to address challenges and increasing engagement of local government committees and other sectors to sustain gains. Conclusion: Our findings offer insights into how a multicomponent implementation strategy influenced changes in the delivery of evidence-based TDT. In addition, the results illustrate the dynamic interplay between barriers and facilitators for sustaining TDT at the policy and community/practice level, particularly in the context of centralized public health systems like Vietnam’s. Sustaining gains in practice improvement and clinical outcomes will require strategies that include ongoing engagement with policymakers and other stakeholders at the national and local level, and planning for adaptations and subsequent resource allocations in order to meet the World Health Organization’s goals promoting access to effective treatment for all tobacco users.
Accounting for Blood Pressure Seasonality Alters Evaluation of Practice-Level Blood Pressure Control InterventionGepts, T., Nguyen, A. M., Cleland, C., Wu, W., Pham-Singer, H., & Shelley, D.
Journal titleAmerican Journal of Hypertension
Page(s)220-222AbstractBackground: Despite the large body of literature evaluating interventions to improve hypertension management, few studies have addressed seasonal variation in blood pressure (BP) control. This underreported phenomenon has implications for interpreting study findings and informing clinical care. We share a methodology that accounts for BP seasonality, presented through a case study - HealthyHearts NYC, an intervention aimed at increasing adherence to the Million Hearts BP control evidence-based guidelines in primary care practices. Methods: We used a randomized stepped-wedge design (n = 257 practices). Each intervention included 13 visits from practice facilitators trained in improving practice-level BP control over 12 months. Two models were used to assess the intervention effect - one that did not account for seasonality (model 1) and one that did (model 2). Model 2 was a re-specification of model 1 to include our proposed two fixed-effects terms to address BP seasonality. Results: Model 1 showed a significant negative association between the intervention and BP control (IRR = 0.98, 95% CI = 0.96-0.99, P ≤ 0.05). In contrast, Model 2, which did address seasonality, showed no intervention effect on BP control (IRR = 0.99, 95% CI = 0.97-1.01, P = 0.19). Conclusions: These findings reveal that analyses that do not account for BP seasonality may not present an accurate picture of intervention effects. In our case study, accounting for BP seasonality turned a negative association into a null association. We recommend that when evaluating BP control, studies compare outcome measures across similar seasons and that the measurement period last long enough to account for seasonal effects.
Attributes of High-Performing Small Practices in a Guideline Implementation: A Multiple-Case StudyNguyen, A. M., Cuthel, A. M., Rogers, E. S., Van Devanter, N., Pham-Singer, H., Shih, S., Berry, C. A., & Shelley, D. R.
Journal titleJournal of Primary Care and Community Health
Volume11AbstractObjective: HealthyHearts NYC was a stepped wedge randomized control trial that tested the effectiveness of practice facilitation on the adoption of cardiovascular disease guidelines in small primary care practices. The objective of this study was to identify was to identify attributes of small practices that signaled they would perform well in a practice facilitation intervention implementation. Methods: A mixed methods multiple-case study design was used. Six small practices were selected representing 3 variations in meeting the practice-level benchmark of >70% of hypertensive patients having controlled blood pressure. Inductive and deductive approaches were used to identify themes and assign case ratings. Cross-case rating comparison was used to identify attributes of high performing practices. Results: Our first key finding is that the high-performing and improved practices in our study looked and acted similarly during the intervention implementation. The second key finding is that 3 attributes emerged in our analysis of determinants of high performance in small practices: (1) advanced use of the EHR; (2) dedicated resources and commitment to quality improvement; and (3) actively engaged lead clinician and office manager. Conclusions: These attributes may be important determinants of high performance, indicating not only a small practice’s capability to engage in an intervention but possibly also its readiness to change. We recommend developing tools to assess readiness to change, specifically for small primary care practices, which may help external agents, like practice facilitators, better translate intervention implementations to context.