Home Engineering Behavioral Intervention Research: Designing, Evaluating, and Implementing
DETERMINING AN INTERVENTION'S DISSEMINATION POTENTIAL
Prior to engaging in dissemination, one must first evaluate whether a proven intervention has the potential to be effectively distributed and subsequently adopted by individuals, communities, and/or clinical settings. However, this is not a straightforward calculus. Existing but limited literature suggests that a proven intervention can be evaluated for its dissemination and ultimately its implementation potential based upon five considerations: the characteristics of the intervention, environmental context in which it would be delivered, fit between the intervention and the context or practice setting, leadership capacity, and access to communication channels. Each of these is discussed in the sections that follow.
Assessing Intervention Characteristics
The first consideration when evaluating the dissemination potential of an intervention concerns its delivery characteristics. Rogers (2003) identified five important characteristics of interventions: relative advantage, compatibility, complexity, trialability, and observability. Each characteristic, defined in Table 21.2, is not necessarily intrinsic to an intervention, but reflects how the intervention may be perceived or experienced by the organization, interventionist, and/or end beneficiary of an intervention.
There is not an agreed-upon understanding of the set of intervention characteristics that enhance its dissemination potential. Characteristics of an intervention have to be evaluated in relationship to the particular goals and outcomes being sought, the target population, and the particular location and context in which it
TABLE 21.2 Characteristics Influencing Dissemination and Adoption of an Intervention
will be deployed. However, behavioral intervention researchers should critically examine the delivery characteristics of their interventions in the formative phases of developing an intervention (see Chapters 3 and 5) in order to understand whether the intervention may scale easily in the future or require a lot of effort such as hiring specialized staff, a prolonged or extensive training period to deliver the program, and/or resources such as special equipment, technology, space, or supplies.
An investigator must balance between developing a potent intervention and the real-world exigencies imposed by practice environments where it might be implemented. For example, an intervention that requires a specific skill set for its delivery may not be able to be adopted by settings that do not have access to the specialized staff (see further discussion of this matter in Chapter 20). This is illustrated by the Collaborative Care program, a primary care model for depression in older adults. Collaborative Care, originally known as IMPACT (Improving Mood—Promoting Access to Collaborative Treatment), was initially tested in an eight-site, randomized clinical trial and found to be twice as effective in reducing depression as usual care with significant cost savings (Unutzer et al., 2002, 2008). Collaborative Care, however, was (and is) not immediately compatible with most primary care practices. The model requires a care manager, psychologist or social worker who is integrated into the practice. However, most primary care practices do not have easy access to such staff, and many do not have sufficient numbers of older patients to make Collaborative Care a priority. Furthermore, the program’s resulting cost benefits do not accrue directly to practices in fee-for-service environments. Since 2002, with the primary publication of trial outcomes (Unutzer et al, 2002), more than 6,000 clinicians have received training in Collaborative Care, and the interventionists have provided resources, training, coaching, and psychiatric consultation to more than 1,000 clinics around the world (Powers, 2015). This objectively impressive number, however, is modest when compared to the more than 200,000 primary practices in the country (Agency for Healthcare Research and Quality, 2011). That said, the rise of Accountable Care Organizations (ACO), interest in patient-centered medical homes, and new Medicare reimbursements for care coordination suggest that Collaborative Care may be more financially attractive for health systems in the future. This illustrates how a variety of contextual considerations (e.g., availability of staff, census of practices, financial incentives, and health policies) influence uptake of a needed intervention.
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