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In this short report, the challenges and lessons learned from implementing scientific research in primary care are discussed. It highlights the complexities of conducting studies in primary care, where ‘Lasagna’s Law’ rules too often. Using the CONCRETE trial – a pragmatic multicenter implementation trial – as an example, eight key elements are identified as important factors for successfully conducting scientific research in primary care, such as optimizing digital processes and improving engagement.
Task-shared psychological treatments play a critical role in addressing the global mental health treatment gap, yet their integration into routine care requires further study. This study evaluated the causal association between an implementation factor of a task-shared psychological treatment and participant outcomes to strengthen the implementation-to-outcome link within global mental health. This secondary analysis utilized cohort data from the Program for Improving Mental Health Care (PRIME) implemented in Sehore, India where trained non-specialist health workers delivered treatment for depression and alcohol use disorder (AUD). Propensity scores and inverse probability of treatment weights examined the impact of mental health service users’ treatment attendance on users’ symptom severity (PHQ-9 scores for depression; AUDIT scores for AUD) at 3 and 12-month follow-ups. Among the 240 patients with depression, higher treatment session attendance led to 1.3 points lower PHQ-9 scores (vs. no attendance) and 2.4 points lower PHQ-9 scores (vs. low attendance) at 3 months, with no significant effects at 12 months. Among the 190 AUD patients, treatment session attendance did not have a significant impact on AUDIT scores. Our findings have implications for enhancing treatment session attendance among those with depression within task-shared psychological treatments.
The time lag between when research is completed and when it is used in clinical practice can be as long as two decades. This chapter considers the dissemination and implementation of research findings. It also explores better ways to make research findings understood and used. On the one hand, we recognize the need to get new research into practice as soon as possible. On the other hand, we challenge the trend toward rapid implementation. When results are put into practice prematurely, patients may suffer unnecessary consequences of insufficiently evaluated interventions. We offer several examples of Nobel Prize winning interventions that had unintentional harmful effects that were unknown when the prize was awarded. To address these problems, we support the need for greater transparency in reporting studies results, open access to clinical research data, and the application of statistical tools such as forest plots and funnel plots that might reveal data irregularities.
Chapter 11 explains the supervisory framework under MiCA. Section 11.2 starts with MiCA’s rules for general supervision by national competent authorities (NCAs). Section 11.3 covers EBA’s supervision for significant stablecoins (ARTs/EMTs). Section 11.4 explains MiCA’s product intervention rules, which establish shared supervision between NCAs, the EBA, and the ESMA. Then, Section 11.5 covers MiCA’s extensive system for supervisory cooperation, both among NCAs, between NCAs and EBA, the ESMA, other European authorities, and also with third country authorities. Finally, Section 11.6 explains MiCA’s implementation timeline and implementing measures.
Parenting programs are effective ways to reduce child maltreatment and promote nurturing parent–child relationships. Yet, the potential of faith-based, positive parent programs, particularly those conducted globally at scale, remains underexplored. We conducted a pre-post and 6-month follow-up, single-group study of a faith- and community-based parenting program, Celebrating Families (CF), in 12 countries in sub-Saharan Africa, Central America and South East Asia. Using a train-the-trainers model, faith leaders delivered group-based parenting workshops over 3–5 days to a nonrandomized sample of 2201 caregivers across 12 countries. Data was collected at three time points. Shifts in caregiver attitudes and beliefs were assessed pre- and post, and harsh parenting behaviors were measured at pre- and 6-months after CF parent program implementation. Acceptability was demonstrated by high attendance and high satisfaction ratings from facilitators and caregivers. Trained faith and community leaders feasibly delivered the CF parent groups and were rated by caregivers to have strong teaching skills. Qualitative analysis of their feedback at 6-month follow-up highlighted barriers to implementation and areas for improvement. Results with those caregivers who completed the program suggest large to medium effect size improvements in caregiver attitudes around harsh discipline and nurturing parenting by country and change in reported use of harsh parenting behaviors at 6 months. Findings suggest that CF is a feasible and acceptable program with promising short-term effects for caregivers of children and adolescents in low- and middle-income countries.
Mentorship education has been shown to positively impact the experiences of mentors and mentees. Entering Mentoring, an evidence-based mentor training curriculum, has been widely implemented to train research mentors across the country, including the mentors of clinical and translational scientists. Facilitating Entering Mentoring, a train-the-trainer based workshop, has been used as a dissemination strategy to increase the number of facilitators prepared to implement mentor training in their local contexts. The objective of this research was to examine individual and institutional factors promoting and limiting mentor training implementation efforts of trained facilitators.
Methods:
Using the Consolidated Framework for Implementation Research (CFIR), we examined self-reported data from surveys administered annually to Facilitating Entering Mentoring participants. Data analyses included t-tests to compare differences between the implementer and non-implementer groups and binary logistic regression to determine which factors best predict implementation status.
Results:
Factors associated with the inner setting domain were found to have the most impact on implementation efforts, with administrative support, leadership support, and interest from potential participants being the most significant predictors of implementation. Additionally, those who implemented were more likely to report receiving institutional support compared with those who did not implement the intervention. Those who did not implement were more likely to report the presence of perceived institutional barriers.
Conclusions:
The CFIR model provides a useful framework for understanding factors that promote and limit implementation outcomes of an evidence-based research mentor training intervention. Findings emphasize the role of institutional support to promote the implementation of research mentor training.
This chapter examines the international legal framework on biodiversity, reflects on the scope of its implementation in the Middle East and North Africa (MENA) region, and highlights the way forward for enhancing coherent, holistic, and integrated implementation of biodiversity treaties in the region. It provides an overview of the status of implementation, primarily through an assessment of the progress of the Strategic Plan for Biodiversity including the Aichi targets (2011–2020), under the Convention of Biological Diversity, and assesses the challenges and opportunities of the post-2020 Global Biodiversity Framework. In addition to a literature review, the chapter analyses information from national reports by parties submitted to secretariats to the CBD and on informational platforms such as UNEP’s InforMEA and Law and Environment Assistance Platform.
Understanding Culture defines culture and identifies why culture is such an important element of the international management context. International management is about leading people and implementing tasks with people across cultural borders. The starting point for effective international management behavior must be a deep understanding of culture. We set the foundation for culture as one of the important contexts of global management. We define culture, examine its different facets, analyze its impact on people, and explore important questions about the intersection of cultures and individual characteristics. Culture serves two important functions for groups. Culture makes action simple and efficient because it creates context for meaning, and it also provides an important source of social identity for its members.
East Asia stands apart from the rest of Asia in the prevalence of the institutionalization of the 1951 Refugee Convention. Despite this widespread adoption of the Convention in East Asia, the record on implementation into domestic law and policy is uneven. This Element offers a comparative analysis of the gap between the institutionalization of the Refugee Convention and the implementation of refugee policy in China, Japan, South Korea, Hong Kong, Taiwan, Macau, and Mongolia. Specific attention is given to two key policy issues: refugee status determination—deciding who is granted government recognition as a refugee—and complementary forms of protection—protection based on statutes other than the Refugee Convention. This Element demonstrates that implementation of the Refugee Convention in East Asia depends on a vibrant civil society with the space and opportunity to engage with local UNHCR offices, local branches of international nongovernmental organizations (INGOs), and other stake holders.
Whereas the previous chapters of this book focused on how to deliver evidence-based CBTx at the patient level, this chapter seeks to consider and challenge readers on how to design, deliver, and implement CBTx for insomnia scale. It outlines the strengths of different delivery methods of CBT (e.g., individual, group, telehealth, books, and digital) and puts forth the case that digital therapeutics (DTx) can serve as a means of fulfilling clinical guideline care for insomnia at scale. Next, the chapter focuses on how guideline-recommended treatment can be delivered in an efficient manner through a stepped care approach that utilises the variety of delivery methods available. The chapter proceeds to outline a care-delivery model at the ecosystem level to treat the widest possible population, taking into account treatment guidelines and real-world examples such as the role of medication and different care pathways. It goes on to describe how to provide a specialised insomnia service within different clinical services and concludes by highlighting key partnerships and alliances for the future of insomnia CBTx.
Evidence-based interventions (EBIs) exist to increase colorectal cancer (CRC) screening, but implementation remains slow in federally qualified health centers (FQHCs). Assessing organizational readiness can improve EBI implementation outcomes, but no studies have quantitatively examined the relation between organizational readiness subcomponents and implementation outcomes. This study examines associations between readiness subcomponents and CRC screening EBI implementation outcomes in FQHCs.
Methods:
We used data from an ongoing parent study to develop an organizational readiness measure using the R = MC2 heuristic. We conducted descriptive and cross-sectional analyses using FQHC clinic (n = 57) data across three states. A clinic contact completed a survey about clinic characteristics and then distributed an EBI-specific survey to clinic staff containing readiness and implementation questions about Community Guide EBIs (e.g., patient reminders). Pearson correlations assessed bivariate associations between readiness variables and implementation outcomes. We then computed multivariable linear associations between readiness variables and implementation outcomes while controlling for clinic-level variables. One-way analysis of variance tested group differences in readiness subcomponent mean scores using EBI implementation responses.
Results:
Respondents’ most common job type was medical assistant, and the most frequently implemented EBIs were provider or patient reminders. Organizational structure was associated with implementing patient reminders. Clinics reporting inconsistent implementation had lower organizational structure scores than clinics planning or fully implementing patient reminders.
Conclusion:
This study guides researchers in prioritizing organizational structure and selecting specific implementation strategies to improve this construct to implement CRC screening-related EBIs. Future research should examine these associations using a larger sample size to explore additional relations between organizational readiness and implementation outcomes.
Based on Dr Colin Espie's 45 years of clinical and research experience, this expert manual for clinicians and healthcare professionals shows how best to assess insomnia and deliver effective treatment in everyday practice using cognitive and behavioural therapeutics (CBTx). The book provides in-depth background on the importance of sleep, the interactions between sleep and health, what insomnia is, and insomnia's negative impact on patients. Using detailed examples, metaphors, and practical guidance, it provides clear instructions on the evaluation of sleep complaints and on the why and how of selecting and providing a specific CBTx to suit the presenting patient. Delving beyond treating patients at the individual level, the book also considers how to develop an effective and efficient insomnia service at population scale.
While there is ample evidence for the efficacy of IPT, confirmed through the results of the efficacy review, on the ground implementation factors are less well understood. We compiled a book on the global reach of IPT by requesting contributions from local authors through word-of-mouth methods. This approach resulted in reports from 31 countries across six continents and 15 diverse populations within the US that spanned the age range and types of usage. In this paper, our aim was to collate and summarize book contributors' descriptions of barriers and facilitators as related to their experiences of implementing IPT across the 31 countries. We conducted a conceptual content analysis and then applied the updated Consolidated Framework of Implementation Research (CFIR) to deductively organize the barriers and facilitators into its five domains. Most found IPT to be relevant and acceptable and described minor variations needed for tailoring to context. National level policies and mental health stigma were highlighted in the outer setting. Availability of specialists and general and mental health infrastructure were considerations relevant to the inner setting. Many sites had successfully implemented IPT through delivery by nonspecialized providers, although provider workload and burnout were common. Clients faced numerous practical challenges in accessing weekly care. Primary strategies to mitigate these challenges were use of telehealth delivery and shortening of the intervention duration. Most programs ensured competency through a combination of didactic training and case supervision. The latter was identified as time-intensive and costly.
Sanctions are intrinsically complex. Implementation of sanctions regulations often entails navigating an extremely dynamic environment consisting of numerous restrictions and prohibitions, difficulties in interpretation, inconsistent measures adopted by imposing jurisdictions and countermeasures. This has been evident following the sanctions against Russia, often described as unprecedented in scale. The more frequent resort to sanctions further means that an increasing number of international contractual relationships are affected. Financial institutions operating globally are particularly impacted. This is exacerbated by the use of secondary sanctions which remain a controversial foreign policy tool and even subject to countermeasures, for example, blocking statutes. Consequently, financial institutions and other economic operators with an international presence, torn between two conflicting regimes, face an unsolvable legal dilemma. This uncertainty extends to the termination of contracts involving persons or activities subject to secondary sanctions. Although in most cases international (financial) contracts contain sanctions clauses (often under force majeure provisions), it remains unclear whether these can be relied on, especially where the institution’s own jurisdiction opposes secondary sanctions. This chapter presents in more detail what are the practical challenges in sanctions implementation. It focuses on financial institutions and provide recommendations on how such challenges could be addressed.
This chapter summarizes the findings from our study, based on the meta-analysis averaging across the effects from the six experiments. We found that increases in locally appropriate community policing practices led to no improvements in citizen–police trust, no greater citizen cooperation with the police, and no reduction in crime. Despite a strong commitment from leadership in each context at the outset, the police implemented the interventions unevenly and incompletely. Although citizens reported more frequent and robust exposure to the police in places where community policing was implemented, we have limited evidence of police action in response to citizen reports.
This article studies the incorporation of package treaties in domestic law and administrative practice, including the functions these treaties serve once in force. This sketch of the domestic operationalization offers a window into the institutional design choices that shape how lawmakers craft the regulatory ecosystem in which flanking policies are carried out. The typology for understanding how governments situate package treaties in their domestic regulatory spaces is introduced, arguing that the ‘package’ of legally binding trade liberalization commitments and mutually agreed flanking policies is shaped by both legislative and regulatory choices that are often underestimated and overlooked. DUS trade agreements are used as a case study, finding that the US government's treatment of each of its trade agreements tends to follow a common pattern: only a small part of the agreement is transposed into domestic law; complex and robust institutions are built around the agreement to embed it deeply into the trade policy work of the executive branch; and, the entrenchment of US trade agreements has a significant enabling effect across a wide range of cross-border regulatory engagements that US agencies think of as ‘monitoring’ or ‘enforcing’, among other labels. Finally, the policy choices against the goals laid out by proponents of package treaties are assessed.
Chapter 6 develops an integrated framework of leader–subordinate dynamics in Chinese SOEs. How do leaders interact with subordinates to execute their agendas, and how do subordinates respond? Grounded in reward, coercion, and legitimate bases of power, the chapter identifies SOE leader tactics such as leveraging position authority, conducting personnel ploys, emphasizing material and status gains, invoking external threats, underscoring superiors’ directives and policies, and appealing to subordinates’ personal duty and morality. Subordinates may react by praising and supporting the leader or by expressing alternative views, delaying or subverting implementation, shirking, engaging in critical expression, or quitting. Leader–subordinate interactions are iterative and evolve over time.
Low-intensity psychological interventions are effective for children and young people (CYP) with mental health difficulties and can help bridge the demand–capacity gap. Despite increasing awareness, training and use of low-intensity psychological interventions, it is not yet understood what is being implemented in clinical practice in the UK and the associated evidence base.
Method:
This paper presents two studies; first, a national survey (n=102) of practitioners to identify low-intensity psychological interventions currently delivered in practice and second, an exploration of the availability and the strength of empirical support (characterised as ‘gold’, ‘silver’ and ‘bronze’) of low-intensity CBT interventions for CYP.
Results:
The first study found a wide variety of interventions being used across different services; 101/102 respondents reported using routine outcome measures. The second study identified 44 different low-intensity interventions, 28 of which were rated as having gold empirical support. However, only 13 of the gold interventions were considered accessible for practitioners and only two were reported being used in routine practice.
Conclusion:
These findings highlight that these interventions have been developed and empirically tested, but many are not easily accessible, highlighting the ‘research–practice’ gap in the provision of low-intensity interventions. There is a need for an increase in standardisation of care and accessibility of gold interventions. This paper hopes to begin the process of creating a hub of low-intensity interventions that are accessible and empirically supported to improve equity of access and outcomes of low-intensity psychological interventions for CYP.
National guidance recommends that relatives of people with dementia receive support to develop coping strategies. STrAtegies for RelaTives (START) is an evidence-based manualised intervention for delivery on a one-to-one basis by trained graduate psychologists to family carers of people with dementia. However, implementation of START in standard National Health Service (NHS) provision has proved difficult. We describe collaboration between a Talking Therapies service and a Memory Service to co-facilitate and run START as a group. We consider implementation outcomes according to RE-AIM domains showing: the collaboration reached higher number of carers than other implementation initiatives (reach); there was significant reduction in caregiver anxiety and a trend towards significant reduction in depression (effectiveness); feedback from service users and clinicians on the service model has been positive (adoption); delivery has been supported by the written and audio materials (implementation); and the initiative has sustained over five years, despite the COVID-19 pandemic and staff turnover (maintenance). Finally, we discuss implications and potential future development.
Key learning aims
(1) To develop knowledge about the content of the STrAtegies for RelaTives (START) coping intervention for family carers of people with dementia.
(2) To understand the similarities between low-intensity cognitive behavioural therapy for anxiety and depression, as provided by Psychological Wellbeing Practitioners (PWPs), and START psychoeducational content and skills exercises.
(3) To reflect on the rationale for group delivery of START.
(4) To consider the benefits of collaboration between Talking Therapies and Memory Services for implementing START.