Department of Health Management and Policy, School of Public Health, University of Michigan, SPH II, 1415 Washington Heights, Ann Arbor, MI, 48109, USA.
Department of Psychiatry, Michigan Medicine, University of Michigan, Ann Arbor, USA.
Implement Sci. 2022 Jul 8;17(1):42. doi: 10.1186/s13012-022-01211-w.
Schools increasingly provide mental health services to students, but often lack access to implementation strategies to support school-based (and school professional [SP]) delivery of evidence-based practices. Given substantial heterogeneity in implementation barriers across schools, development of adaptive implementation strategies that guide which implementation strategies to provide to which schools and when may be necessary to support scale-up.
A clustered, sequential, multiple-assignment randomized trial (SMART) of high schools across Michigan was used to inform the development of a school-level adaptive implementation strategy for supporting SP-delivered cognitive behavioral therapy (CBT). All schools were first provided with implementation support informed by Replicating Effective Programs (REP) and then were randomized to add in-person Coaching or not (phase 1). After 8 weeks, schools were assessed for response based on SP-reported frequency of CBT delivered to students and/or barriers reported. Responder schools continued with phase 1 implementation strategies. Slower-responder schools (not providing ≥ 3 CBT components to ≥10 students or >2 organizational barriers identified) were re-randomized to add Facilitation to current support or not (phase 2). The primary aim hypothesis was that SPs at schools receiving the REP + Coaching + Facilitation adaptive implementation strategy would deliver more CBT sessions than SPs at schools receiving REP alone. Secondary aims compared four implementation strategies (Coaching vs no Coaching × Facilitation vs no Facilitation) on CBT sessions delivered, including by type (group, brief and full individual). Analyses used a marginal, weighted least squares approach developed for clustered SMARTs.
SPs (n = 169) at 94 high schools entered the study. N = 83 schools (88%) were slower-responders after phase 1. Contrary to the primary aim hypothesis, there was no evidence of a significant difference in CBT sessions delivered between REP + Coaching + Facilitation and REP alone (111.4 vs. 121.1 average total CBT sessions; p = 0.63). In secondary analyses, the adaptive strategy that offered REP + Facilitation resulted in the highest average CBT delivery (154.1 sessions) and the non-adaptive strategy offering REP + Coaching the lowest (94.5 sessions).
The most effective strategy in terms of average SP-reported CBT delivery is the adaptive implementation strategy that (i) begins with REP, (ii) augments with Facilitation for slower-responder schools (schools where SPs identified organizational barriers or struggled to deliver CBT), and (iii) stays the course with REP for responder schools.
ClinicalTrials.gov, NCT03541317 , May 30, 2018.
学校越来越多地为学生提供心理健康服务，但往往缺乏实施策略来支持基于学校的（和学校专业人员[SP]）实施循证实践。鉴于学校之间实施障碍存在很大的异质性，因此可能需要制定适应性实施策略，指导为哪些学校和何时提供哪些实施策略，以支持扩大规模。
采用密歇根州高中的聚类、顺序、多次分配随机试验（SMART），为支持 SP 提供的认知行为疗法（CBT）制定学校层面的适应性实施策略提供信息。所有学校首先提供基于复制有效项目（REP）的实施支持，然后随机分配是否增加面对面辅导（第 1 阶段）。8 周后，根据 SP 报告向学生提供 CBT 的频率和/或报告的障碍，对学校进行反应评估。有反应的学校继续实施第 1 阶段的实施策略。反应较慢的学校（未向≥10 名学生提供≥3 个 CBT 部分或报告>2 个组织障碍）被重新随机分配是否增加当前支持的促进（第 2 阶段）。主要目标假设是，接受 REP+辅导+促进适应性实施策略的学校的 SP 将提供更多的 CBT 课程，而接受单独 REP 的学校的 SP 则提供更多的 CBT 课程。次要目标比较了四种实施策略（辅导与不辅导×促进与不促进）在提供的 CBT 课程上的差异，包括小组、简短和全个人的 CBT 课程。分析采用为聚类 SMART 开发的边际加权最小二乘法。
共有 94 所高中的 169 名 SP 参加了这项研究。N = 83 所学校（88%）在第 1 阶段后反应较慢。与主要目标假设相反，REP+辅导+促进与单独的 REP 之间在提供的 CBT 课程数量上没有证据表明存在显著差异（111.4 与 121.1 次平均总 CBT 课程；p=0.63）。在次要分析中，提供 REP+促进的适应性策略导致了最高的平均 CBT 交付（154.1 次），而提供 REP+辅导的非适应性策略导致了最低的平均 CBT 交付（94.5 次）。
就 SP 报告的 CBT 提供的平均数量而言，最有效的策略是适应性实施策略，该策略（i）从 REP 开始，（ii）为反应较慢的学校（即 SP 确定组织障碍或难以提供 CBT 的学校）提供促进，（iii）为反应良好的学校继续提供 REP。
ClinicalTrials.gov，NCT03541317，2018 年 5 月 30 日。
