Contributions to the literature
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This work advances the conceptual basis and study of bridging factors and is the first manuscript to specify and define bridging factor dimensions for implementation research.
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Through our novel application of the functions and forms framework, we propose a core set of dimensions that lays the groundwork for bridging factor reporting and measurement.
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Enhanced operationalization of bridging factors will help researchers and practitioners proactively leverage strategies that can strengthen linkages across outer and inner contexts to improve implementation outcomes and public health impact.
Background
The need for a bridging factors research agenda to advance implementation research and practice
Integrating bridging factors with existing organizational theories and concepts
Summary of our argument
Methods
Case selection
Code development and application
Sample
Case number and title | 1. Contracting arrangements | 2. Policy-driven fiscal incentive | 3. Community-academic partnerships in a LMIC | 4. START model partnerships | 5. Earmarked taxes | 6. State-wide interagency collaboration | 7. Data sharing process | 8. Partnership between state and local child welfare agencies | 9. Site-level accreditation process | 10. Individual as a bridging factor | |
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Study details | |||||||||||
Intervention "The thing" | SafeCare® | Multiple EBPs | Healthy Beginnings | START model | Not EBP specific | EBPs for autism spectrum disorder | Evidence-based HIV interventions | R3 supervision focused implementation approach | SafeCare® | Programming for incarcerated pregnant and postpartum women | |
Bridging factor | Contracting arrangements between public sector child welfare systems and organizations delivering the EBP | Policy-driven fiscal incentive that connected a public sector mental health system and organizations delivering the EBPs | Partnership between the local government in LMIC setting and churches | Partnership between substance use treatment organizations and local child welfare agencies | Earmarked taxes that connected states with public sector mental health systems and organizations delivering the EBPs | Interagency collaboration among a state and organizations delivering the EBPs | Data sharing process that connected local and state health departments with organizations delivering the EBPs | Partnership between state and local child welfare agencies | Site-level accreditation process that connected program developers with organizations delivering the EBP | An individual who connected a university medical center with a state-run prison | |
Function dimensions | |||||||||||
1 | Type | Formal arrangement | Formal arrangement | Relational tie | Relational tie | Formal arrangement | Relational tie | Process | Relational tie | Process | Relational tie |
2 | Outer context | Public sector child welfare system | Public sector mental health system | Local government in LMIC setting | Substance use treatment organizations in the community | State(legislators and voting constituents) | State (policymakers) | Local and state health departments | State (system leadership) | Program developers | University medical center |
3 | Inner context | Organizations delivering the EBP | Organizations delivering the EBPs | Churches | Local child welfare agencies | Public sector mental health systems, organizations delivering the EBPs | Organizations delivering the EBPs | Organizations delivering the EBPs | Local child welfare agencies | Organizations delivering the EBP | State-run prison |
4 | Capital exchanged | Money, EBP expertise, institutional knowledge, training/coaching capacity, flow of eligible clients, social capital with program developer | Money, EBP expertise, institutional knowledge, training/coaching capacity, flow of eligible clients, social capital with program developer | Money, EBP expertise, training | Money, referrals, case-level client information, social norms, staff | Money | Social capital, involvement of sources of power, strategic alignment with existing infrastructure and resources | Data/information, money | Money, policies and procedures, required expectations, performance reviews (job security, opportunities for promotion) | EBP information, implementation data, social norms and sense of community, networking opportunities | Provider time, free access to experts, positive publicity for the university, tangible resources |
5 | Impact on outer and inner contexts | Outer and inner: provides structure for measuring, reporting, and providing the EBP | Outer and inner: provides structure for measuring and reporting clinical outcomes, and providing the selected EBPs | Outer and inner: provides care pathway to increase screening and retention in care | Outer and inner: provides a care pathway; Inner only: expands staff, provides structure for data management | Outer and inner: money flow from taxpayers to local jurisdictions | Outer and inner: synergy across state-wide policy, existing resources and organizations, infrastructure for sustainable training | Outer only: public health mission and ability to obtain financial resources; No direct benefit to inner | Outer and inner: bridging factor failure contributed to implementation failure in both inner and outer contexts | Outer only: see rationale. Inner only: can help secure contracts, provides outward legitimacy, information sharing across sites, may increase awareness around internal processes | Outer only: community impact, access to new sources of grant money and other research resources Inner only: generation of program data and information about the target population |
Form dimensions | |||||||||||
1a | Rationale | Community- academic partnerships | Political | Public health concern | Public health concern, model requirement | Political, public health concern | Political, regulatory, and community need | Regulatory, public health concern | Existing system structure | Program developers’ needs including the desire to better track implementation across sites | Individual’s decision-making and action |
1b | Implementation strategy | No | No | Yes | No | Yes | Not explicit | No | No | No | No |
1c | Regulatory context | Enforceable | Enforceable, voluntary | Encouraged, voluntary | Encouraged | Mandatory, enforceable | Voluntary | Mandatory | Mandatory, enforced | Voluntary but required if you want to provide SafeCare | Voluntary, unenforced |
2a | Duration | Varied by system | Short-term | Long-term | Long-term | Short-term | Both | Long-term | Long-term | Long-term | Long-term |
2b | Changes across implementation phases | Yes | Yes | Maybe | Maybe | Ideally | Yes | No | Yes | If program developer changes requirements | If policies change |
2c | Supports | Contracting person in service system, existing resources | Service system division, existing resources | NGO, existing and new resources | Training from model purveyors, Regional Behavioral Health Boards, money, existing and new resources | Legislation, existing and new resources | Implicit support from state government, high degree of collaboration, existing resources | Legislation, new resources | Existing resources rather than specific supports | Varies by site, some existing some new | Flexibility that comes with an academic position and the ability to print program materials |
3a | Multiple systems | Yes | No | Yes | Yes | No | Yes | Yes | Yes | Yes | Yes |
3b | General or specific | General | General | Specific | General | General | General to EBPs for ASD | General | General | General | General |
3c | Outcomes | EBP adoption, implementation and sustainment, staff turnover | EBP sustainment, staff retention | EBP sustainment | EBP fidelity, penetration, service outcomes (esp. timeliness) | EBP adoption and sustainment, workforce capacity, downstream clinical improvements | EBP adoption, implementation and sustainment | Equity, reduced number of new infections, EBP sustainment | Forced partnership led to failed EBP implementation, discontinuation of trainings, discontinuation of sustainment plan | EBP sustainment, “fidelity to the implementation process” | Reduced recidivism, improved infant health and bonding, increased client engagement, sustainability, reduced legal risk for the prison |
Results
Bridging factor dimensions: organized by functions and forms
Function dimensions: core characteristics that define the bridging factor and speak to its purpose as it relates to EBP implementation | |
1. Type(s) | Relational tie, formal arrangement, and/or process? |
2. Outer context | What is the outer context? |
3. Inner context | What is the inner context? |
4. Capital exchanged | What capital (e.g., fiscal, knowledge, norms, communication, resources) is exchanged through the bridging factor? |
5. Impact on outer and/or inner context | How does the bridging factor impact the outer and/or inner context? |
Form dimensions: characteristics that help us understand the specific structures, activities, and strategies that illustrate why and how the bridging factor has been customized to a local implementation experience | |
1. Origin | |
a. Rationale | Why and/or how was the bridging factor created? |
b. Implementation strategy | Is the bridging factor a planned and deliberate implementation strategy? |
c. Regulatory context | Is the bridging factor enforceable, mandatory, encouraged, and/or voluntary? |
2. Dynamism | |
a. Duration | Is the bridging factor short or long term? |
b. Change across the implementation phases | How does the bridging factor change or require modifications across the implementation phases? |
c. Supports | What resources or structures support the bridging factor and how stable are those supports? Does the bridging factor leverage existing resources and supports or require building new ones? |
3. Scope | |
a. Multiple systems | Does the bridging factor cross multiple service systems? |
b. General or specific | Is the bridging factor general across EBPs or specific to a particular EBP? |
c. Outcomes | How does the bridging factor affect implementation, clinical, and/or service outcomes? |