The implementation and sustainment facilitation strategy improved implementation effectiveness and intervention effectiveness: Results from a cluster-randomized, type 2 hybrid trial

Abstract

Background: Substance use disorders (SUDs) among people with HIV are both prevalent and problematic. The Substance Abuse Treatment to HIV care project was funded to test the Implementation and Sustainment Facilitation (ISF) strategy as an adjunct to the Addiction Technology Transfer Center (ATTC) strategy for integrating a motivational interviewing-based brief intervention (MIBI) for SUDs within HIV community-based organizations. Methods: Using a cluster-randomized, type 2 hybrid trial design, 39 HIV organizations were randomized to either (1) ATTC ( n = 19) or (2) ATTC + ISF ( n = 20). Each HIV organization identified two staff members to be prepared to implement the MIBI ( N = 78). Subsequently, during the implementation phase, HIV organizations in each condition randomized client participants ( N = 824) to one of the two intervention conditions: usual care (UC; n = 415) or UC + MIBI ( n = 409). Both staff-level outcomes and client-level outcomes were examined. Results: The ISF strategy had a significant impact on the implementation effectiveness (i.e., the consistency and the quality of implementation; β = .65, p = .01) but not on time-to-proficiency (β = −.02) or level-of-sustainment (β = .09). In addition, the ISF strategy was found to have a significant impact on the intervention effectiveness (the effectiveness of the MIBI), at least in terms of significantly decreasing the odds (odds ratio = 0.11, p = .02) of clients using their primary substance daily during follow-up. Conclusion: The ISF strategy was found to be an effective adjunct to the ATTC strategy in terms of implementation effectiveness and intervention effectiveness. It is recommended that future efforts to integrate the project’s MIBI for SUD within HIV organizations use the ATTC + ISF strategy. However, given the ISF strategy did not have a significant impact on level-of-sustainment, implementation research testing the extent to which the ATTC + ISF strategy can be significantly enhanced through effective sustainment strategies is warranted. Plain language abstract Substance use among people living with HIV is associated with increased mental health problems, worse medication adherence, and worse HIV viral suppression. Increasing substance use-related services in HIV community-based organizations is an important public health need. The Substance Abuse Treatment to HIV care project tested two strategies for helping HIV organizations implement a brief intervention (BI) designed to motivate clients to decrease their substance use. The project also tested if receiving a BI improved clients’ outcome. Two staff from each of the 39 participating organizations were taught how to deliver the BI using the Addiction Technology Transfer Center (ATTC) training strategy (online and in-person training, monthly feedback, and coaching). Half of the organizations also received the Implementation and Sustainment Facilitation (ISF) strategy, which included monthly meetings with an ISF coach for the two BI staff and one or more leadership staff from the organization. Organizations that received both the ATTC and ISF strategies delivered more BIs and higher quality BIs than organizations that only received the ATTC strategy. In addition, clients receiving BIs at organizations that received both strategies were more likely to decrease their substance use. However, receiving both strategies did not improve how quickly staff learned to deliver the BI or improve the number of BIs delivered during the project’s 6-month sustainment phase. Future research focused on implementing BIs within HIV organizations should consider using the ATTC and ISF strategies while also seeking to enhance the strategies to improve sustainment.

Project MIMIC (Maximizing Implementation of Motivational Incentives in Clinics): A cluster-randomized type 3 hybrid effectiveness-implementation trial

“…For this reason, additional strategies may be needed to accelerate and sustain implementation of CM. Prior implementation research by our team supports the effectiveness and cost-effectiveness of both Pay-for-Performance [ 37 , 38 ], and Implementation & Sustainment Facilitation [ 39 , 40 ] to improve implementation and client outcomes relative to didactic training, feedback, and on-going consultation. The Pay-for-Performance strategy accelerates implementation via the extrinsic motivation of implementing staff members, whereas the Implementation & Sustainment Facilitation strategy promotes sustainment by drawing on the intrinsic motivation of the broader staff of a treatment organization.…”

The Setting-Intervention Fit of Nine Evidence-Based Interventions for Substance Use Disorders Within HIV Service Organizations Across the United States: Results of a National Stakeholder-Engaged Real-Time Delphi Study

“…As such, key stakeholders seeking to help improve the integration of motivational interviewing for substance use or SUDs within HSOs are encouraged to explore the 2 motivational interviewing–based interventions shown to be effective within HSO settings. 13,39 In contrast to motivational interviewing, the average SIF score was at or slightly below the midpoint for cognitive behavioral therapy and contingency management. Nonetheless, cognitive behavioral therapy did seem to be a good fit for clinical HSOs, where the SIF index score for cognitive behavioral therapy was above the midpoint and significantly greater than SIF scores reported by nonclinical HSOs.…”

“…Another large-scale effort to integrate SUD services within HSO settings was the Substance Abuse Treatment to HIV Care (SAT2HIV) Project, which was completed in 2020. 13 A dual-randomized type 2 implementation-effectiveness hybrid trial, 14 the SAT2HIV Project simultaneously tested 2 strategies for helping HSOs integrate a motivational interviewing-based brief intervention for SUDs 15 and tested the effectiveness of the motivational interviewing-based intervention as an adjunct to usual care. 15 Relative to usual strategies (ie, training, ongoing performance feedback, and ongoing intervention consultation), the Implementation and Sustainment Facilitation Strategy significantly improved implementation effectiveness (ie, the consistency and quality of implementation) and intervention effectiveness (ie, the effectiveness of the intervention for reducing substance use).…”

Reflections on 10 years of effectiveness-implementation hybrid studies

“…Type 2 hybrids could be powered on the health outcome, the implementation outcome, or both, depending on the research design and number of clusters. Type 2 hybrids beg for dual randomized research designs in which units are assigned to both an intervention and an implementation strategy (28), but for various reasons (e.g., feasibility and resources necessary), these are uncommon. Thus, researchers often need to decide on which outcome to power a type 2.…”