Use of implementation theory: a focus on PARIHS.

BACKGROUND: Limited understanding and application of theory in implementation research contributes to variable effectiveness of implementation studies. Better understanding of direct experiences with theory could improve implementation research and the potency of interventions. AIMS: This study was a conceptual exercise aimed at characterizing experiences with and applications of the Promoting Action on Research Implementation in Health Services (PARIHS) framework. METHODS: This was a structured, qualitative study involving document reviews and interviews used to answer the following overarching questions about nine implementation research centers: Why and how was PARIHS used? What strengths and weaknesses were identified for PARIHS? FINDINGS: PARIHS was being used for varied purposes, at varied levels, in varied ways, and to a varying extent within and across centers. Lack of implementation theory use in investigators' early years was common. Variability in the nature of theory use was attributable to characteristics of the centers, individual investigators, and features of PARIHS. Strengths and weaknesses of the PARIHS framework were identified. LINKING EVIDENCE TO ACTION: The study provides information to researchers and theorists about the use of one well-known implementation framework. The information suggests areas for improvements in PARIHS as well as theory use in general, and should assist in the development of theory-based programs of research.

Associations between perceptions of evidence and adoption of H1N1 influenza infection prevention strategies among healthcare workers providing care to persons with spinal cord injury.

AIM: To examine associations between perceptions of evidence (research evidence, clinical expertise, patient preferences) and outcomes of a nationwide programme to implement H1N1 influenza prevention guidelines. BACKGROUND: Healthcare workers do not consistently adhere to recommended infection control practices and this may be associated with their perceptions of evidence sources. DESIGN: Cross-sectional mailed survey. METHOD: A survey of healthcare workers was administered in August 2010 after implementation of H1N1 prevention guidelines. Outcomes of interest were ratings of adherence to H1N1 prevention guidelines. FINDINGS: Respondents with complete data (N = 283) were included in analyses. Facility-level adherence to guidelines was associated with opinions of clinical experts. Healthcare workers who rated clinical expertise as aligning with recommendations also rated their facilities as being more adherent to guidelines. Perceptions of research evidence and patient preferences were not associated with facility adherence. Personal adherence was not associated with perceptions of evidence, except among those healthcare workers who rated both clinical experts and patients as unsupportive of guidelines; these practitioners were less likely to adhere to recommended personal hygiene practices. CONCLUSION: Efforts to implement guidelines might be most effective when capitalizing on the influence of clinical experts. To better explain variability in guideline adherence, inclusion of a broader array of variables is recommended for future studies.

Depression, healthcare utilization, and comorbid psychiatric disorders after spinal cord injury.

BACKGROUND: Depression is often comorbid with other psychiatric conditions in the general population, with resultant impact on severity of conditions and healthcare utilization. It is unclear to what degree this is also true among persons with spinal cord injury (SCI). OBJECTIVE: This study examined rates at which psychiatric conditions were comorbid with depression after SCI, and the association between a depression diagnosis and healthcare and pharmaceutical drug use. METHODS: Retrospective analysis of data (N = 41 213) abstracted from Veterans Health Administration administrative databases between fiscal years (FYs) 1997 and 2007 to examine overall rates of depression. Administrative data from FY 2007 was used to examine rates of psychiatric disorders comorbid with depression, and to compare veterans with SCI and depression to veterans with SCI but no depression on healthcare and pharmaceutical use. RESULTS: Twenty-eight percent (n = 11 506) of 41 213 veterans who received SCI care between FY 1997 and FY 2007 were diagnosed with depressive disorders. Among the veterans with SCI and depression diagnoses in 2007 (n = 2615), 70% were also diagnosed with another psychiatric illness, with posttraumatic stress disorder and other anxiety disorders being the most common. Veterans with SCI and depression had more healthcare visits and received more pharmaceutical prescriptions than their counterparts without depression. CONCLUSIONS: Persons with SCI and depression are likely to experience comorbid psychiatric illnesses, with associated increased healthcare visits and medication use. Research and theory on depression after SCI should develop toward describing and addressing psychiatric and medical co-morbidities that are normative in this population.

Pain, depression, and health care utilization over time after spinal cord injury.

OBJECTIVE: The aim of this research was to examine comorbid pain and depression after spinal cord injury (SCI) in terms of: frequency, longitudinal course, and associations with medical conditions and use of SCI specialty care. METHOD: Three consecutive standardized annual psychological evaluations were reviewed for 286 persons with SCI receiving care at an SCI specialty care center. Chart abstraction included medical and demographic information, a depression scale, and a pain scale. Administrative databases were used to collect SCI specialty care utilization data. Participants were categorized as having elevated pain, elevated depression, both elevated pain and depression, or neither elevated, using cut-off scores on the pain and depression scales. ANOVA and repeated measures ANOVA were used to compare study groups. RESULTS: Approximately 20% of the sample showed both elevated pain and depression at Year 1. Persons with elevated pain and depression showed higher scores on those measures than did persons with either pain or depression alone. Pain scores tended to be stable over time. Depression scores tended to improve over 3 years, but persons with elevated pain and depression showed less improvement on depression scores than did persons with depression alone. Persons with pain and depression tended to utilize more SCI specialty care. CONCLUSIONS: Pain and depression are often comorbid after SCI. This comorbidity is associated with higher pain and depression severity, more persistent pain and depression over time, and more use of SCI specialty care. Comorbid pain and depression should be anticipated among persons with SCI and addressed in care plans.

Pain and post-traumatic stress disorder symptoms during inpatient rehabilitation among operation enduring freedom/operation iraqi freedom veterans with spinal cord injury.

OBJECTIVE: To examine the frequency of post-traumatic stress disorder (PTSD) symptoms and pain, and how PTSD symptoms were associated with pain severity ratings and the longitudinal course of pain during inpatient rehabilitation for spinal cord injury (SCI) among veterans of the Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) conflicts. DESIGN: Longitudinal analysis of data gathered from electronic medical records. SETTING: SCI specialty care centers within the Department of Veterans Affairs. PARTICIPANTS: Veterans of the OEF/OIF conflicts (N=87) who received inpatient rehabilitation for SCI and disorders at Department of Veterans Affairs SCI centers between May 2003 and October 2009. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE(S): PTSD screening at start of rehabilitation and pain numeric rating scale measurements completed throughout rehabilitation. Cut-scores were used to categorize participants into 1 of 4 groups on the basis of scores at the start of rehabilitation: Pain and PTSD, Pain Alone, PTSD Alone, Neither Condition. RESULTS: Comorbid pain and PTSD symptoms were more common than either condition alone, and nearly as common as not having either condition. Participants with pain at the start of rehabilitation (Pain and PTSD, Pain-Alone groups) showed declines in pain ratings over the course of rehabilitation. In contrast, participants in the PTSD-Alone group showed increasing pain over the course of rehabilitation. CONCLUSIONS: Pain and PTSD symptoms may be more likely to manifest as comorbidities than as isolated conditions during inpatient rehabilitation. Assessment routines and care plans should be prepared with comorbidities as a foremost concern. It is advisable to screen for pain and PTSD at multiple time points during inpatient rehabilitation to detect new or emerging concerns.

Activity and participation after spinal cord injury: state-of-the-art report.

The importance of activities and community participation for persons with spinal cord injury (SCI) has been recognized for decades and yet theoretical and empirical advances have been limited. This report summarizes the recommendations for researchers on the topic of measuring activity and participation among persons with SCI formulated by the Spinal Cord Injury workgroup at the State-of-the-Art Conference on Outcome Measures in Rehabilitation held in January 2010. Activity and participation were defined as independent constructs ideally measured in reference to personal values and environmental influences. Measures of activity, participation, and factors influencing activity and participation are reviewed and critiqued. Gaps in available measures are described, measures in development are discussed, and suggestions for future research are made.

A critical synthesis of literature on the promoting action on research implementation in health services (PARIHS) framework.

BACKGROUND: The Promoting Action on Research Implementation in Health Services framework, or PARIHS, is a conceptual framework that posits key, interacting elements that influence successful implementation of evidence-based practices. It has been widely cited and used as the basis for empirical work; however, there has not yet been a literature review to examine how the framework has been used in implementation projects and research. The purpose of the present article was to critically review and synthesize the literature on PARIHS to understand how it has been used and operationalized, and to highlight its strengths and limitations. METHODS: We conducted a qualitative, critical synthesis of peer-reviewed PARIHS literature published through March 2009. We synthesized findings through a three-step process using semi-structured data abstraction tools and group consensus. RESULTS: Twenty-four articles met our inclusion criteria: six core concept articles from original PARIHS authors, and eighteen empirical articles ranging from case reports to quantitative studies. Empirical articles generally used PARIHS as an organizing framework for analyses. No studies used PARIHS prospectively to design implementation strategies, and there was generally a lack of detail about how variables were measured or mapped, or how conclusions were derived. Several studies used findings to comment on the framework in ways that could help refine or validate it. The primary issue identified with the framework was a need for greater conceptual clarity regarding the definition of sub-elements and the nature of dynamic relationships. Strengths identified included its flexibility, intuitive appeal, explicit acknowledgement of the outcome of 'successful implementation,' and a more expansive view of what can and should constitute 'evidence.' CONCLUSIONS: While we found studies reporting empirical support for PARIHS, the single greatest need for this and other implementation models is rigorous, prospective use of the framework to guide implementation projects. There is also need to better explain derived findings and how interventions or measures are mapped to specific PARIHS elements; greater conceptual discrimination among sub-elements may be necessary first. In general, it may be time for the implementation science community to develop consensus guidelines for reporting the use and usefulness of theoretical frameworks within implementation studies.

Pain, depression, and physical functioning following burn injury.

OBJECTIVE: Little is known about how pain and depression after burn injury may influence long-term outcomes such as physical functioning. This prospective study examined associations between pain, depression, and physical functioning in a sample of burn injury survivors. DESIGN AND PARTICIPANTS: Questionnaires assessing pain, depression, and physical functioning were completed by 64 (52% of original sample) adult burn survivors shortly after discharge from burn care and at 1- and 2-year follow-ups. RESULTS: Pain and physical functioning improved over the 2 years of the study, whereas depression levels were stable. Pain and depression were associated with poorer physical functioning over time, but associations varied according to the time span under consideration. Also, the association between pain and physical functioning was strongest among persons with higher depression scores. CONCLUSIONS: Pain and depression may contribute independently to compromises in physical functioning. The co-occurrence of pain and depression represents even greater risk for reduced physical functioning over time among burn survivors.

Pain among veterans with spinal cord injury.

The Department of Veterans Affairs Veterans Health Administration cares for approximately 15% of persons with spinal cord injury (SCI) in the United States. However, the nature and characteristics of pain among veterans with SCI are not well understood. This study used a postal survey to compare veterans with SCI and nonveterans with SCI on pain intensity; pain interference; functioning; and other pain, demographic, and medical characteristics. Veterans tended to be older than nonveterans but these groups were otherwise comparable on demographic and medical variables. Veterans were not significantly different from nonveterans on pain intensity or pain interference. Veterans reported lower levels of functioning than nonveterans and higher levels of pain-related catastrophizing. However, differences in functioning between veterans and nonveterans were attributable to age differences between the groups. In summary, differences between veterans with SCI and nonveterans with SCI were few and small in magnitude, suggesting that veterans with SCI are not at greater risk for pain and pain-related problems. However, pain-related catastrophizing may be a particular concern among veterans with SCI.

Adjustment and discussion of cancer: a comparison of breast and prostate cancer survivors.

Supportive conversations may facilitate adjustment among cancer patients early in treatment. However, little is known about how cancer discussion is related to adjustment among long-term survivors of cancer or how gender differences may influence associations between cancer discussion and adjustment. The purpose of this study was to examine possible moderator effects of gender on associations between cancer discussions and adjustment among survivors of breast or prostate cancer. Eighty-eight breast and 88 prostate cancer patients were matched by years post-surgery and stage of cancer and completed measures of cancer discussion frequency, quality of life, and depression. Breast and prostate cancer patients differed on what cancer-related threats were discussed most frequently. In addition, among breast, but not prostate cancer patients, frequent cancer discussion was associated with higher depression and lower quality of life. Frequent discussion of cancer may be an indication of poorer adjustment among breast cancer patients at nearly four years post-surgery. The nature and context of cancer discussions may be important determinants of whether cancer discussions relate to adaptive versus maladaptive outcomes.

Physiologic reactivity to a laboratory stress task among men with benign prostatic hyperplasia.

OBJECTIVES: The sympathetic nervous system and hypothalamic-pituitary-gonadal axis are involved in the pathophysiology of benign prostatic hyperplasia (BPH). The sympathetic nervous system and hypothalamic-pituitary-gonadal axis are also highly reactive to psychological stressors, yet associations between prostate function and reactivity to a psychological stressor have not been examined using standardized psychological stress paradigms. The objective of this study was to examine the associations between psychological stress reactivity and BPH disease parameters. METHODS: A total of 83 men diagnosed with BPH completed a standardized laboratory stress task, yielding measures of blood pressure, testosterone, and cortisol reactivity. Links were examined between stress reactivity (as indicated by changes in blood pressure, testosterone, and cortisol during the stress task) and measures of BPH disease, including prostate volume, postvoid residual bladder volume, urine flow rate, self-reported lower urinary tract symptoms, and impact and bother scores. RESULTS: In equations controlling for BPH medications, body mass index, and age, greater diastolic blood pressure reactivity was associated with a greater transition zone volume (P <0.001), greater total prostate gland volume (P <0.05), greater postvoid residual bladder volume (P <0.05), more severe lower urinary tract symptoms (P <0.001), and greater impact scores (P <0.05). Greater cortisol reactivity was associated with greater bother (P <0.05) and impact (P <0.001) scores. CONCLUSIONS: Physiologic reactivity to a standardized laboratory stressor is associated with objective and subjective BPH disease parameters. These findings contribute to growing data suggesting that stress conditions could be associated with the development or aggravation of prostatic disease.

Prevalence of depression diagnoses and use of antidepressant medications by veterans with spinal cord injury.

OBJECTIVES: The objectives of this study were to examine the prevalence of depression diagnoses among veterans with spinal cord injuries and disabilities (SCI&D) for a 3-yr period, and to characterize patterns of antidepressant medication use in this population. DESIGN: This study was a retrospective analysis of clinical and administrative data. The sample consisted of 3678 veterans with SCI&D who had received any health care at a Department of Veterans Affairs facility between fiscal years 1999 and 2001, a depression diagnosis, and complete data. Logistic regression analysis was used to examine associations between patient characteristics, antidepressant types, and prescription patterns. RESULTS: Approximately 22% of veterans with SCI&D received a diagnosis of depression during at least one encounter with a healthcare provider. Of those diagnosed, 72% received antidepressant prescriptions. However, a large percentage (67%) did not continue antidepressant use for 6 mos. Patients started on a selective serotonin reuptake inhibitor were more likely to have at least 6 mos of continuous use than patients started on other, newer antidepressants. CONCLUSIONS: Many veterans with SCI&D may not be receiving adequate treatment for depression. Veterans with SCI&D should be aggressively screened and treated for depression, and further research is necessary to determine which treatments for depression are most effective for persons with SCI&D.

Pain following spinal cord injury.

Pain is one of the most common, severe, and treatment-resistant complications that follows SCI. Recent years have seen a surge of research on methods for assessing and treating spinal cord injury pain. In this article, pain after SCI is reviewed in terms of nature, scope, assessment techniques, and treatment strategies.

Cold pressor pain sensitivity in monozygotic twins discordant for chronic fatigue syndrome.

OBJECTIVE: Individuals with chronic fatigue syndrome (CFS) experience many pain symptoms. The present study examined whether pain and fatigue ratings and pain threshold and tolerance levels for cold pain differed between twins with CFS and their cotwins without CFS. DESIGN: Cotwin control design to assess cold pain sensitivity, pain, and fatigue in monozygotic twins discordant for CFS. PATIENTS AND SETTING: Fifteen monozygotic twin pairs discordant for CFS recruited from the volunteer Chronic Fatigue Twin Registry at the University of Washington. RESULTS: Although cold pain threshold and tolerance levels were slightly lower in twins with CFS than their cotwins without CFS, these differences failed to reach statistical significance. Subjective ratings of pain and fatigue at multiple time points during the experimental protocol among twins with CFS were significantly higher than ratings of pain (P = 0.003) and fatigue (P < 0.001) by their cotwins without CFS. CONCLUSIONS: These results, while preliminary, highlight the perceptual and cognitive components to the pain experience in CFS. Future studies should focus on examining the heritability of pain sensitivity and the underlying mechanisms involved in the perception of pain sensitivity in CFS.

Stress is associated with subsequent pain and disability among men with nonbacterial prostatitis/pelvic pain.

BACKGROUND: Nonbacterial prostatitis is a syndrome characterized by persistent pelvic area pain in men with or without voiding symptoms. Its causes are poorly understood, and evidence-based treatments are lacking. Although psychological stress has been proposed as an etiological factor, the literature lacks prospective studies using standardized measures to examine associations between stress and male pelvic pain problems over time. PURPOSE: This study examined whether perceived stress was associated longitudinally with pain intensity and pain-related disability in a sample of men with nonbacterial prostatitis/pelvic pain. METHODS: Men (N = 224) completed measures of perceived stress, pain intensity, and pain-related disability 1 month after a health care visit with a new nonbacterial prostatitis/pelvic pain diagnosis and 3, 6, and 12 months later. RESULTS: Greater perceived stress during the 6 months after the health care visit was associated with greater pain intensity (p = .03) and disability (p = .003) at 12 months, even after controlling for age, symptom duration, and pain and disability during the first 6 months. CONCLUSIONS: These findings support further research into the associations between stress and male pelvic pain syndromes, as well as the assessment of stress in the evaluation of patients with pelvic pain.

Stress, hostility, and disease parameters of benign prostatic hyperplasia.

OBJECTIVE: Psychological factors such as stress are known to influence activity in the sympathetic nervous system and hypothalamic-pituitary-gonadal axis, systems that in turn have been implicated in the development of benign prostatic hyperplasia (BPH). Associations between psychological stress and prostate function have not been directly examined. The objective of this study was to examine associations among stress, hostility, and BPH disease parameters. METHODS: Eighty-three men diagnosed with BPH completed self-report and interview measures of stress and hostility followed by measures of urologic function. RESULTS: Higher lifetime stress was associated with lower prostate volumes and residual urine volumes (p's < .05). By contrast, high recent stress and hostility were associated with greater residual urine (p's < .05). Stress and hostility were not associated with self-report ratings of urologic symptoms. CONCLUSIONS: Stress and hostility were associated with objective measures of urologic functioning among men with BPH. Results highlight the need for increased attention in research and clinical settings toward associations between psychological factors and urologic disease.

Cancer fear and mood disturbance after radical prostatectomy: consequences of biochemical evidence of recurrence.

PURPOSE: Biochemical recurrence of prostate cancer often precedes any clinical sign or symptom of disease recurrence by several years. Thus, patients may have laboratory evidence of recurrence and do not know what it portends in terms of the future disease course. Little is known about the emotional consequences of biochemical recurrence. We compared cancer fear and mood disturbance in men with biochemical recurrence of prostate cancer versus those without recurrence. In addition, associations among urinary symptoms, cancer fear and mood disturbance were examined. MATERIALS AND METHODS: A survey including the American Urological Association symptom index, a cancer fear measure and the Profile of Mood States was mailed to patients at a urology clinic at a tertiary care hospital in 1999. Of the sample of 270 patients with prostate cancer who underwent radical prostatectomy 126 (47%) responded to the mailed survey. A total of 45 men with biochemical prostate cancer recurrence were compared to 81 patients without recurrence. RESULTS: Higher urinary tract symptoms were associated with increased cancer fear and mood disturbance (each p <0.05). Biochemical cancer recurrence was not independently associated with increased cancer fear and mood disturbance. However, men with biochemical recurrence and more severe urinary tract symptoms reported the highest levels of cancer fear and mood disturbance (each p <0.01). CONCLUSIONS: Psychological distress was highest in men with biochemical recurrence and elevated clinical symptoms. Urinary symptoms may be an important contributor to psychological distress in patients with prostate cancer who have biochemical recurrence.

Concealment of homosexual identity, social support and CD4 cell count among HIV-seropositive gay men.

OBJECTIVE: Previous research has indicated that the concealment of homosexuality is related to poorer health among gay men with HIV. This study explored mechanisms by which concealment of homosexuality may be related to HIV disease status by examining associations between concealment of homosexuality, social support, social constraints, depressive symptoms and CD4 count among HIV-seropositive gay men. METHOD: Questionnaires assessing concealment of homosexuality, social support, depressive symptoms and social constraints were administered to 73 HIV-seropositive gay men. Medical charts were accessed to gather HIV disease information including CD4 counts. Regression analyses were conducted to examine associations between psychosocial variables and CD4 counts. RESULTS: Concealment of homosexuality was associated with lower CD4 count, greater social constraints, greater depressive symptoms and less social support. The association between concealment of homosexuality and CD4 count varied according to level of social support. Among participants with higher levels of social support, those with greater concealment had lower CD4 counts than those with lower concealment. Concealment of homosexuality was not related to CD4 count among participants reporting low social support. CONCLUSION: Concealment of homosexuality among HIV-seropositive gay men is associated with lower CD4 counts, depressive symptoms and strained social relationships. In addition, the benefits of being open about homosexuality may be most evident under conditions of greater social support.