Commentary on “Is Theory Guiding Our Work? A Scoping Review on the Use of Implementation Theories, Frameworks, and Models to Bring Community Health Workers into Health Care Settings.”
In the past few years, colleagues and I have conducted mixed methods evaluations of innovations designed to transform health care service delivery for the Centers for Medicare & Medicaid Services.(Bir, 2018; Rojas-Smith, 2017). One such innovation includes the integration of community health workers (CHWs) into health care settings and we found many interesting findings regarding the implementation experience of organizations who tried to implement such innovations. A common barrier experienced by organizations included the lack of role and responsibility clarity for CHWs; both from the CHW perspective but also from the perspective of other health care team members. Further, the types of roles and activities performed by CHWs was highly varied as was the training, background, and experiences of individuals working in such roles. Thus, when I was selecting abstracts to feature in this month’s newsletter, I was intrigued by the scoping review by Allen et al. regarding the use of implementation theories, frameworks, and models to bring CHWs into health care settings.
The authors identified 50 articles published since 2000 evaluating CHW interventions within health care settings for this scoping review. Diabetes and cancer were the two most commonly targeted disease conditions (14 and 11 studies respectively). Ten studies focused on low-income or poor populations and 19 studies were focused on CHWs in clinic settings. The authors reported that studies often did not describe methods of CHW recruitment or background of the CHWs, specifically the community to which the CHWs belonged. In 9 studies, CHWs were described as being members of the health care team.
Across the 50 included studies, 30 different theories were used and 24 of these theories were what the study authors described as ‘classic’ theories originating from a field other than implementation science (e.g., psychology, organizational management). Community-based participatory research and cultural tailoring were the most commonly used theories (9 studies and 8 studies, respectively). Only 6 implementation theories were used: cultural tailoring, PRECEDE-PROCEED, intervention mapping, RE-AIM, diffusion of innovation, and the collaborative-care model. Further, studies generally lacked clear operationalization and evaluation of implementation science constructs, and studies did not apply theory at the organizational level, which would be critical to influencing the integration of CHWs within health-care settings. The authors conclude that the use of implementation theory applied at multiple levels (e.g., individual and organizational) could help improve the integration of CHWs into health care settings.
The findings from this scoping review did not surprise me and were very consistent with my own experience evaluating such interventions. Interventions that integrate CHWs into health care settings are complex interventions that require a lot of planning, training, and monitoring. Although classic theory may guide the use of CHWs to improve care delivery or health outcomes; traditional theory may not support a robust implementation of such complex interventions or help evaluators distinguish between intervention failure or implementation failure. In order for decision makers to know whether they should invest resources in CHW integration, we need better science regarding the best way to implement such interventions and this scoping review is helpful for identifying the gaps in that science.
Read the full abstract.
Bir, A., Smith, K., Kahwati, L., Derzon, J., Freeman, N., Emery, K., Stockdale, H., Cohen, J., Koethe, B., Kane, H., & Liebling, E. (2018). Health Care Innovation Awards (HCIA) Meta-Analysis and Evaluators Collaborative Third Annual Report. Retrieved from https://downloads.cms.gov/files/cmmi/hcia-metaanalysisthirdannualrpt.pdf
Rojas-Smith, L., Amico, P., Hoerger, T., Jacobs, S., Payne, J., & Renaud, J. (2017). Evaluation of the Health Care Innovation Awards: Community Resource Planning, Prevention, and Monitoring. Retrieved from https://downloads.cms.gov/files/cmmi/hcia-communityrppm-thirdannualrpt.pdf