Expect the unexpected: A qualitative study of the ripple effects of children’s mental health services implementation efforts

Abstract

Background Strategies to implement evidence-based interventions (EBIs) in children’s mental health services have complex direct and indirect causal impacts on multiple outcomes. Ripple effects are outcomes caused by EBI implementation efforts that are unplanned, unanticipated, and/or more salient to stakeholders other than researchers and implementers. The purpose of the current paper is to provide a compilation of possible ripple effects associated with EBI implementation strategies in children’s mental health services, to be used for implementation planning, research, and quality improvement. Methods Participants were identified via expert nomination and snowball sampling. Online surveys were completed by 81 participants, each representing one of five roles: providers of mental health services to children or youth, researchers, policy makers, caregivers, and youth. A partially directed conventional content analysis with consensus decision making was used to code ripple effects. Results Four hundred and four unique responses were coded into 66 ripple effects and 14 categories. Categories include general knowledge, skills, attitudes, and confidence about using EBIs; general job-related ripple effects; EBI treatment adherence, fidelity, and alignment; gaming the system; equity and stigma; shifting roles, role clarity, and task shifting; economic costs and benefits; EBI treatment availability, access, participation, attendance, barriers, and facilitators; clinical process and treatment quality; client engagement, therapeutic alliance, and client satisfaction; clinical organization structure, relationships in the organization, process, and functioning; youth client and caregiver outcomes; and use of EBI strategies and insights in one’s own life. Conclusions This research advances the field by providing children’s mental health implementers, researchers, funders, policy makers, and consumers with a menu of potential ripple effects. It can be a practical tool to ensure compliance with guidance from Quality Improvement/Quality Assurance, Complexity Science, and Diffusion of Innovation Theory. Future phases will match potential ripple effects with salient children’s mental health implementation strategies for each participant role. Plain Language Summary: This qualitative study of multiple stakeholders in children’s mental health services identifies several possible ripple effects of implementation strategies, opening a new area of study for implementation science. Ripple effects can be positive, negative, or neutral within the full balance of implementation quality and impact. The list of ripple effects will provide implementation scientists, developers, and others with a useful tool during implementation planning and evaluation. This expert-informed methodology can provide a model for other fields for exploring possible ripple effects within implementation science.

Specifying cross-system collaboration strategies for implementation: a multi-site qualitative study with child welfare and behavioral health organizations

“…Future studies are needed to test these and other potential strategies to determine their impact on implementation speed and service timeliness [ 61 ] considering the inconsistent evidence about whether referral protocols lead to quicker treatment [ 62 ]. Additional research is needed to investigate the ethics and potential unintended consequences [ 63 ] of expedited access agreements. Although these agreements can facilitate quick treatment access [ 60 ], they might also privilege clients based on their case status (e.g., status as a parent/guardian) or those referred from one type of agency over another regardless of treatment needs (e.g., [ 64 ]) which has potential to create or widen inequities in child welfare outcomes.…”

Strategies for enacting health policy codesign: a scoping review and direction for research

“…However, the cross-service model developed strongly resembled existing evidence-informed recommendations while also including innovative components (e.g., peer navigation support). This and other literature suggest research evidence can be a valuable information source but should not dominate and sometimes may not be necessary (or could be harmful) when designing policies and systems to solve intractable health problems [ 75 , 76 ]. The promise of policy codesign, albeit in an infant stage, is having a framework for selecting and synthesizing information and engaging partners to create the most transformative or effective policy solution possible for that moment.…”

Developing ethical standards for dissemination and implementation research: a roadmap for consensus and guidance

“…Field-specific questions related to the scope and methods of monitoring, reporting, and responding to adverse events, defining minimal risk and other constructs relevant to waiving or modifying informed consent must be carefully elaborated in this consensus seeking process. Map implementation strategies to unintended consequences Second, Pullman and colleagues identified 13 categories of potential unintended consequences, or ripple effects, of implementation strategies to promote uptake of evidence-based interventions for children’s mental health services [ 23 ]. Categories of positive or negative unintended consequences can serve as a guide upon which implementation strategies can be mapped with domain definitions related to feasibility, frequency, impact, timeframe, measurement, and mitigation.…”

“…Second, Pullman and colleagues identified 13 categories of potential unintended consequences, or ripple effects, of implementation strategies to promote uptake of evidence-based interventions for children’s mental health services [ 23 ]. Categories of positive or negative unintended consequences can serve as a guide upon which implementation strategies can be mapped with domain definitions related to feasibility, frequency, impact, timeframe, measurement, and mitigation.…”