Using Implementation Mapping to Increase Uptake and Use of Salud en Mis Manos: A Breast and Cervical Cancer Screening and HPV Vaccination Intervention for Latinas

"Stakeholder engagement played a critical role..."

Despite recommendations for breast and cervical cancer screening and human papillomavirus (HPV) vaccination, cancer control behaviours are underutilised among low-income Latinas in the United States (US). Salud en Mis Manos (SEMM) is an evidence-based intervention (EBI) adapted from Cultivando La Salud (CLS), a community health worker (CHW)-delivered breast and cervical cancer screening behavioural intervention developed for Mexican-American women living in farmworkers communities. SEMM components include CHW-delivered education and referrals and health-coach-navigator-delivered barrier mitigation to help women overcome personal and system-level barriers to accessing and using clinic services. While proven effective in a randomised controlled trial, SEMM has had limited uptake and implementation in clinical settings. The present study used implementation mapping (IM) to develop Salud en Mis Manos-Dissemination and Implementation Assistance (SEMM-DIA), a multifaceted implementation strategy designed to build capacity of clinic leadership and management, intervention champions, and CHWs to plan, manage, implement, and maintain SEMM.

Informed by theories and models, IM is a step-by-step protocol that incorporates empirical evidence and stakeholder input and feedback. The development of SEMM-DIA used the IM framework to help integrate behavioural theory [i.e., Social Cognitive Theory (SCT)] to identify behavioural determinants at multiple levels (e.g., organisation and CHW) and implementation frameworks, including the Interactive Systems Framework for Dissemination and Implementation (ISF) and the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework. To guide planning evaluation outcomes, the researchers used RE-AIM, focusing on Reach, Effectiveness, Implementation, and Maintenance (intention).

The IM planning process also supports a community-engaged approach to implementation strategy development, helping to integrate multiple stakeholder perspectives throughout development. Using a community-engagement approach, the researchers included perspectives of stakeholders with previous experience implementing the SEMM intervention, as well as people with insight into the clinic practice setting (e.g., clinic leaders, clinic managers, and CHWs) who could also represent the patient perspective, such as patients' concerns regarding undergoing cancer screening and barriers to completing screening services.

Specifically, the researchers used IM's 5 iterative tasks to develop strategies to accelerate and improve implementation fidelity, reach, and maintenance of the SEMM intervention. In brief, the process included:

1. Task 1. Conduct an implementation needs and assets assessment: The research team conducted 12 semi-structured Zoom-based interviews with clinic personnel representing clinic leadership, mid-management, and CHWs at 4 different Texas, US, community health centres. They considered both health behaviour theory (i.e., SCT) and implementation science frameworks (i.e., Interactive Systems Framework and Organizational Readiness) during the identification of factors potentially influencing implementation. For example, regarding potential facilitators, leadership participants stressed the importance of intra-organisational relationships, stating that obtaining clinic staff buy-in for intervention implementation is important.
2. Task 2. State implementation and maintenance outcomes, performance objectives (e.g., who must do what to implement SEMM?), and determinants to create matrices of change objectives: As part of this process, the researchers crossed performance objectives and determinants and asked, "what has to change in X determinant in order to accomplish this implementation performance objective?" For example, the ISF domain "motivation" guided the selection of specific attitudinal determinants expected to influence implementation and maintenance of the programme.
3. Task 3. Choose theoretical methods, and identify or design implementation strategies: The researchers considered theoretical change methods (both those focused on changing behaviour and those focused on influencing the implementation environment) that could address determinants identified in Task 2. They created practical applications of those methods such that they were feasible and appropriate for use in clinic settings. For example, based on their influence on determinants (e.g., attitudes, self-efficacy, and skills) and contextual factors, guided by SCT, the team identified behavioural change methods (e.g., modeling verbal persuasion, and communication). These methods were operationalised to guide adaptation of the existing CHW manager trainings. Task 3 was also conducted in partnership with stakeholder engagement, e.g., those with previous experience implementing SEMM, as well as clinic and CHW experiences in general.
4. Task 4. Produce implementation protocols and materials to guide intervention implementation: The researchers identified, adapted, or produced the SEMM implementation protocols, materials, and tools to include in the SEMM-DIA implementation package. For example, the SEMM-DIA website was designed to be a multi-faceted multi-component implementation support strategy to guide planning and implementation of the SEMM EBI. A design document was developed to be the "blueprint" to guide construction of the SEMM-DIA website. They also developed documentation to support clinic stakeholders' implementation planning and process monitoring of SEMM. The overarching goal of this implementation strategy package was to provide clear, user-friendly support to promote feasibility, and fidelity of implementation.
5. Task 5. Evaluate the implementation outcomes: The evaluation plan included measures to assess organisational readiness for implementation, level of implementation, determinants of implementation, experiences with implementing SEMM, and implementation maintenance. Selection of mediators and moderators of implementation was guided by behavioural theoretical constructs based on SCT and ISF identified during the planning process. A logic model was developed that is thought to be especially useful for communicating both the evaluation outcomes and the causal mechanisms of the SEMM implementation and evaluation plan to non-academic clinic or community partners.

Reflecting on this experience, the researchers identify what they consider to be strengths of this work, such as:

• The IM process used to plan SEMM-DIA provides a model to help identify common challenges to implementation and maintenance specific to CHW-delivered interventions. Strategies identified may benefit other CHW-delivered interventions, and they include: (i) provide online CHW training materials to help maintain continuity of the program when there is CHW turnover, (ii) embed materials developed to promote the programme to reduce difficulty accessing materials in a timely manner, and (iii) provide CHW manager training materials to develop manager capacity to deliver CHW training, and provide continuous support and motivation to CHWs.
• IM includes, as a foundational principle, the integration of implementers, community partners, and other interested parties in the strategy development process. By engaging stakeholders with different roles and from different clinic settings, the researchers were able to develop relevant and feasible methods and strategies with consideration of multiple perspectives and contingencies. Thus, throughout the process, they provided tailored options within the implementation strategies to influence different determinants and performance objectives for different types of users. The approach helped maximise generalisability of the SEMM-DIA design to a variety of potential users, as well as to diverse clinic and environmental contexts. One of the challenges with this collaborative approach was scheduling meetings with clinic leadership and healthcare providers who often have competing priorities.

In conclusion: "The development of SEMM-DIA provides an opportunity to illustrate how Implementation Mapping can help implementation strategy planners use theory, evidence, and community engagement to inform strategy selection and tailoring. The use of Implementation Mapping also results in a logic model that presents a graphic depiction of the planned linkages between the implementation strategy, mechanisms, determinants of implementation and proximal and distal implementation outcomes, helping to describe the SEMM-DIA strategy's mechanisms of change....To promote implementation of evidence-based behavioral interventions into community practice, increased reporting of processes used to select and tailor and develop implementation strategies are needed. This paper begins to fill that gap."