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February 18, 2013

'Implementation Science' May Help Providers Adopt New Treatments Despite Real-World Constraints

by Matthew Chinman, Joie D. Acosta, Patricia A. Ebener

Much of today's research on health problems tests new treatments under ideal conditions. However, providers, especially those in smaller community-based settings, often have difficulty using these new treatments. This is because community-based providers operate under much tougher conditions than the conditions in which the treatments were tested. They usually have less funding, equipment, expertise, time, and staff—collectively called capacity—than the original research trials. Thus, if the first problem of health interventions is finding new and better treatments, getting those treatments to patients across the range of health delivery settings can be thought of as the “second problem.”

A new field called implementation science has been developed in the last 5 to 10 years to specifically address this “second problem”—that is, how to best support providers to take up new, research-proven treatments and implement them well. Implementation science is growing, especially in medicine. For example, a recent analysis of 23 studies found that primary care settings had greater use of research-proven treatments when they had external consultants promoting their use. However, there is little implementation science in non-clinical settings where prevention programs are delivered by community-based organizations under even tougher conditions. Because a great deal of services are provided in these tough community-based settings, implementation science is needed there, too.

Researchers at the RAND Corporation are conducting this kind of implementation science in a new 5-year study called Enhancing Quality Interventions Promoting Healthy Sexuality, or EQUIPS. The study, whose methods are described in a new paper in Clinical and Translational Science, tests how well Boys & Girls Clubs of America (i.e., a community-based setting) carries out a prevention program proven to prevent teen pregnancy and sexually transmitted infections (called Making Proud Choices), with and without an intervention called Getting To Outcomes®. Getting To Outcomes® is a toolkit, training, and onsite support package designed to build community-based providers' capacity to plan, implement, and self-evaluate proven programs. Thirty-two Boys & Girls Club sites will receive training on Making Proud Choices and half (chosen at random) will also receive Getting To Outcomes®. At each site, the study will assess hours of Getting To Outcomes® support received; quality of programming; and sexual knowledge, attitudes, and behaviors of the participating youth.

EQUIPS is unique because it addresses several areas often missing in implementation science research. First, many implementation studies only evaluate implementation quality but do not measure individual outcomes as well. EQUIPS will do both. If successful, it will be the first time it has been shown that improving capacity of community providers can improve youth outcomes in teen pregnancy and sexually transmitted infections. Second, implementation studies are not always able to show how programs or outcomes improve. The research procedures in EQUIPS will specifically test links between Getting To Outcomes® support, capacity, implementation quality, and youth outcomes. Third, many implementation studies are not able to test whether their strategies have an impact over longer periods of time—i.e., sustainability. By removing the Getting To Outcomes support halfway through the project while continuing to track capacity and implementation quality, EQUIPS will evaluate its own sustainability. Finally, EQUIPS is on a scale (32 sites, nearly 1000 youth) similar to the strategies being conducted at the national level, meaning the results will offer more reliable and valid lessons.

Moreover, while some implementation studies may have one or more of these evaluation elements, few have all of them in combination, as EQUIPS does. Therefore, the EQUIPS study could serve as a model for implementation science research that could begin to solve health issues' “second problem” and potentially bring promising new treatments to health care delivery settings where they might not otherwise have been available.


Matt Chinman and Joie Acosta are behavioral scientists and Patricia Ebener is a project associate at the nonprofit, nonpartisan RAND Corporation.