What will it take? Using an implementation research framework to identify facilitators and barriers in implementing a school-based referral system for sexual health services

Abstract

Background: Across the United States, sexually transmitted infections and unintended pregnancy rates are alarmingly high among youth. Schools, due to their proximity and access to youth, can increase student access to sexual health services (SHS) by creating referral systems (RS) to link students to school-and community-based SHS. From 2013 to 2018, the Centers for Disease Control and Prevention's Division of Adolescent and School Health funded 17 Local Education Agencies (LEA) to partner with priority schools and stakeholders to develop and implement RS to increase student access to SHS. Cicatelli Associates Inc. (CAI) was funded to provide capacity-building to LEA. In 2016-2017, CAI conducted case studies at two LEA, both large and urban sites, but representing different geographical and political contexts, to elucidate factors that influence RS implementation. Methods: Nineteen LEA and community-based healthcare (CBH) staff were interviewed in the Southeastern (n = 9) and Western U.S. (n = 10). Key constructs (e.g., leadership engagement, resources, state and district policies) across the five domains of the Consolidated Framework for Implementation Research (CFIR) framework guided the methodology and analysis. Qualitative data was analyzed using the Framework Method and contextual factors and themes that led to RS implementation were identified. Results: Interviewees strongly believed that school-based RS can decrease STI, HIV and unintended pregnancy and increase students' educational attainment. We identified the following contextual key factors that facilitate successful implementation and integration of an RS: enforcing state and district policies, strong LEA and CBH collaboration, positive school culture towards adolescent health, knowledgeable and supportive staff, leveraging of existing resources and staffing structures, and influential district and school building-level leadership and champions. Notably, this case study challenged our initial assumptions that RS are easily implemented in states with comprehensive SHS policies. Rather, our conversations revealed how districts and local-level policies can have significant impact and influence to impede or promote those policies.

The Use of the Consolidated Framework for Implementation Research to Understand Facilitators and Barriers to Sexually Transmitted Infection Screening in Primary Care

“…In leveraging the CFIR, we also demonstrate and discuss how other clinician researchers might apply this framework in promoting uptake and implementation their own evidence-based sexual health interventions in practice. [20][21][22]…”

“…The goal of our study was to understand their roles and perspectives on STI testing and identify local barriers and facilitators to provision of this care, to inform their implementation of the STI screening program. In leveraging the CFIR, we also demonstrate and discuss how other clinician researchers might apply this framework in promoting uptake and implementation their own evidence-based sexual health interventions in practice 20–22 …”

Adolescents’ perceived barriers to accessing sexual and reproductive health services in California: a cross-sectional survey

“…Sexual health education programs can directly address adolescents’ questions and concerns, such as discussing practices to ensure privacy and confidentiality in clinics, as well as providing local clinic information including available services, hours, location, and cost [ 42 ]. Schools may also consider developing formal referral systems to SRH services or providing contraception at school-based health centers [ 43 , 44 ].…”

Considerations in implementation of social risk factor screening and referral in maternal and infant care in Washington, DC: A qualitative study

“…Strengths of our study including using a highly-utilized theoretical framework to understand organizational level impacts on social risk factor screening and referral. The CFIR has been applied to screening and referral processes in alcohol abuse and treatment, cancer, chronic disease, primary care, and school-based sexual health settings [51][52][53][54][55]. Contextualizing screening and referral processes through a widely utilized framework allows for comparison with other clinical setting findings.…”