Gregory A. Aarons

Advancing a Conceptual Model of Evidence-Based Practice Implementation in Public Service Sectors

Implementation science is a quickly growing discipline. Lessons learned from business and medical settings are being applied but it is unclear how well they translate to settings with different historical origins and customs (e.g., public mental health, social service, alcohol/drug sectors). The purpose of this paper is to propose a multi-level, four phase model of the implementation process (i.e., Exploration, Adoption/Preparation, Implementation, Sustainment), derived from extant literature, and apply it to public sector services. We highlight features of the model likely to be particularly important in each phase, while considering the outer and inner contexts (i.e., levels) of public sector service systems.

Implementation Research in Mental Health Services: an Emerging Science with Conceptual, Methodological, and Training challenges

One of the most critical issues in mental health services research is the gap between what is known about effective treatment and what is provided to consumers in routine care. Concerted efforts are required to advance implementation science and produce skilled implementation researchers. This paper seeks to advance implementation science in mental health services by over viewing the emergence of implementation as an issue for research, by addressing key issues of language and conceptualization, by presenting a heuristic skeleton model for the study of implementation processes, and by identifying the implications for research and training in this emerging field.

Mental Health Provider Attitudes Toward Adoption of Evidence-Based Practice: The Evidence-Based Practice Attitude Scale (EBPAS)

Mental health provider attitudes toward organizational change have not been well studied. Dissemination and implementation of evidence-based practices (EBPs) into real-world settings represent organizational change that may be limited or facilitated by provider attitudes toward adoption of new treatments, interventions, and practices. A brief measure of mental health provider attitudes toward adoption of EBPs was developed and attitudes were examined in relation to a set of provider individual difference and organizational characteristics. Methods: Participants were 322 public sector clinical service workers from 51 programs providing mental health services to children and adolescents and their families. Results: Four dimensions of attitudes toward adoption of EBPs were identified: (1) intuitive Appeal of EBP, (2) likelihood of adopting EBP given Requirements to do so, (3) Openness to new practices, and (4) perceived Divergence of usual practice with research-based/academically developed interventions. Provider attitudes varied by education level, level of experience, and organizational context. Conclusions: Attitudes toward adoption of EBPs can be reliably measured and vary in relation to individual differences and service context. EBP implementation plans should include consideration of mental health service provider attitudes as a potential aid to improve the process and effectiveness of dissemination efforts.

Prevalence of Psychiatric Disorders in Youths Across Five Sectors of Care

OBJECTIVE To examine the prevalence of psychiatric disorders among youths from the following five public sectors of care: alcohol and drug services (AD), child welfare (CW), juvenile justice (JJ), mental health (MH), and public school services for youths with serious emotional disturbance (SED) in San Diego, California. METHOD The Diagnostic Interview Schedule for Children was administered between October 1997 and January 1999 for 1,618 randomly selected youths aged 6-18 years who were active in at least one of the five sectors. RESULTS Fifty-four percent of the participants met criteria for at least one study disorder. Attention-deficit/hyperactivity disorder (ADHD) and disruptive behavior disorders (50%) were much more common than anxiety (10%) or mood (7%) disorders. Youths who were active in the MH and SED sectors were more likely than those not in these sectors to meet criteria for a disorder; youths in the CW sector were least likely. CONCLUSIONS Rates of psychiatric disorders, specifically ADHD and disruptive behavior disorders, are extremely high for youths in public sectors of care. Rates are generally higher in sectors designed to serve youths with psychiatric needs, but the prevalence of disorders was also high in sectors not specifically designed for this need (e.g., CW and JJ).

Adolescent substance use and sexual risk-taking behavior

PURPOSE To examine the relationship of adolescent substance use and dependence to sexual risk-taking behavior in late adolescence and young adulthood. METHODS We prospectively examined self-reported sexual behaviors and substance involvement questionnaires in a sample of youth in substance abuse treatment programs and a comparison sample of sociodemographically similar community youths without histories of substance use disorders recruited from media ads. Assessments of sexual behaviors and substance involvement (78% white, 51% female) were collected at 2, 4, and 6 years after initial assessments, as they transitioned from middle adolescence to young adulthood (from age 15.5 to age 21.5 years, on average). The two samples were compared using Chi-square, analysis of variance, and multivariate analysis of variance approaches. Continuous indicators of high-risk sexual behaviors and substance involvement were analyzed with multiple regression. RESULTS Earlier age of onset to sexual activity, more sexual partners, less consistent use of condoms, more sexually transmitted diseases (STDs), and greater prevalence of human immunodeficiency virus testing were reported by youth in the clinical treatment sample relative to sociodemographically comparable nonabusing community youth. High rates of STDs were found among females, and more substance-abusing females reported pregnancies than community females. Substance involvement continued to be associated with high-risk sexual behavior throughout the transition into young adulthood. CONCLUSIONS Youth identified with substance problems are more likely to engage in risky sexual behaviors during adolescence and to continue risky sexual behaviors to the extent that substance problems persist. Risk reduction education should be included with adolescent substance abuse treatment.

Organizational Culture and Climate and Mental Health Provider Attitudes Toward Evidence-Based Practice

Mental health provider attitudes toward adopting evidence-based practice (EBP) are associated with organizational context and provider individual differences. Organizational culture and climate are contextual factors that can affect staff acceptance of innovation. This study examined the association of organizational culture and climate with attitudes toward adopting EBP. Participants were 301 public sector mental health service providers from 49 programs providing mental health services for youths and families. Correlation analyses and multilevel hierarchical regressions, controlling for effects of provider characteristics, showed that constructive culture was associated with more positive attitudes toward adoption of EBP and poor organizational climates with perceived divergence of usual practice and EBP. Behavioral health organizations may benefit from consideration of how culture and climate affect staff attitudes toward change in practice.

Implementation of Evidence-based Practice in Child Welfare: Service Provider Perspectives

Implementation of evidence-based practices (EBP) in child welfare is a complex process that is often fraught with unanticipated events, conflicts, and resolutions. To some extent, the nature of the process, problems, and solutions may be dependent on the perspectives and experiences of a given stakeholder group. In order to better understand the implementation process in the child-welfare system, we interviewed comprehensive home-based services (CHBS) case managers who were actively engaged in implementing an EBP to reduce child neglect in a state youth services system. Six primary factors were identified as critical determinants of EBP implementation: (1) Acceptability of the EBP to the caseworker and to the family, (2) Suitability of the EBP to the needs of the family, (3) Caseworker motivations for using the EBP, (4) Experiences with being trained in the EBP, (5) Extent of organizational support for EBP implementation, and (6) Impact of EBP on process and outcome of services. These factors reflect two broader themes of attitudes toward or assessments of the EBP itself and experiences with learning and delivering the EBP. Eventual implementation is viewed as the consequence of perseverance, experience, and flexibility.

Organizational climate partially mediates the effect of culture on work attitudes and staff turnover in mental health services.

Staff turnover in mental health service organizations is an ongoing problem with implications for staff morale, productivity, organizational effectiveness, and implementation of innovation. Recent studies in public sector services have examined the impact of organizational culture and climate on work attitudes (i.e., job satisfaction and organizational commitment) and, ultimately, staff turnover. However, mediational models of the impact of culture and climate on work attitudes have not been examined. The present study examined full and partial mediation models of the effects of culture and climate on work attitudes and the subsequent impact of work attitudes on staff turnover. Multilevel structural equation models supported a partial mediation model in which organizational culture had both direct influence on work attitudes and indirect influence through organizational climate. Work attitudes significantly predicted one-year staff turnover rates. These findings support the contention that both culture and climate impact work attitudes and subsequent staff turnover.

The impact of evidence-based practice implementation and fidelity monitoring on staff turnover: evidence for a protective effect.

Staff retention is an ongoing challenge in mental health and community-based service organizations. Little is known about the impact of evidence-based practice implementation on the mental health and social service workforce. The present study examined the effect of evidence-based practice implementation and ongoing fidelity monitoring on staff retention in a childrens services system. The study took place in the context of a statewide, regionally randomized effectiveness trial of an evidence-based intervention designed to reduce child neglect. In the study 21 teams consisting of 153 home-based service providers were followed over a 29-month period. Survival analyses revealed greater staff retention in the condition where the evidence-based practice was implemented along with ongoing fidelity monitoring presented to staff as supportive consultation. These results should help to allay concerns about staff retention when implementing evidence-based practices where there is good values-innovation fit and when fidelity monitoring is designed as an aid and support to service providers in providing a high standard of care for children and families.

Psychometric Properties and U.S. National Norms of the Evidence-Based Practice Attitude Scale (EBPAS)

The Evidence-Based Practice Attitude Scale (EBPAS) assesses mental health and social service provider attitudes toward adopting evidence-based practices. Scores on the EBPAS derive from 4 subscales (i.e., Appeal, Requirements, Openness, and Divergence) as well as the total scale, and preliminary studies have linked EBPAS scores to clinic structure and policies, organizational culture and climate, and first-level leadership. EBPAS scores are also related to service provider characteristics, including age, education level, and level of professional development. The present study examined the factor structure, reliability, and norms of EBPAS scores in a sample of 1,089 mental health service providers from a nationwide sample drawn from 100 service institutions in 26 states in the United States. The study also examined associations of provider demographic characteristics with EBPAS subscale and total scores. Confirmatory factor analysis supported a second-order factor model, and reliability coefficients for the subscales ranged from .91 to .67 (total scale = .74). The study establishes national norms for the EBPAS so that comparisons can be drawn for U.S. local as well as international studies of attitudes toward evidence-based practices. The results suggest that the factor structure and reliability are likely generalizable to a variety of service provider contexts and different service settings and that the EBPAS subscales are associated with provider characteristics. Directions for future research are discussed.