EPITalk: Behind the Paper
This stimulating podcast series from the Annals of Epidemiology takes you behind the scenes of groundbreaking articles recently published in the journal. Join Editor-in-Chief, Patrick Sullivan, and journal authors for thought-provoking conversations on the latest findings and developments in epidemiologic and methodologic research.
EPITalk: Behind the Paper
Understanding Organizational Context & Its Role in Implementation Science
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Dr. Larry Hearld illustrates multiple methods that implementation scientists can use to better inform adaptation and implementation of evidence-based interventions in complex organizational settings. “Integrating existing and novel methods to understand organizational context: A case study of an academic-public health department partnership” is published in the December 2024 issue (Vol. 100) of Annals of Epidemiology.
Read the full article here:
https://www.sciencedirect.com/science/article/abs/pii/S1047279724002473
Episode Credits:
- Executive Producer: Sabrina Debas (Episodes 1-18) and Sofina Tran (19-)
- Technical Producer: Paula Burrows
- Annals of Epidemiology is published by Elsevier
Hello, you're listening to EPITalk: Behind the Paper, a monthly podcast from the Annals of Epidemiology. I'm Patrick Sullivan, Editor-in-Chief of the journal, and in this series we take you behind the scenes of some of the latest epidemiologic research featured in our journal. Today we're here with Dr. Larry Hearld to discuss his article "Integrating Existing and Novel Methods to Understand Organizational ontext: A case study of an academic public health department partnership. " Context a case study of an academic public health department partnership. You can read the full article online in the December 2024 issue of the journal at www.annalstofepidemiology.org.
Patrick SullivanOur guest today, Dr. Larry Hearld, is a Professor and Director of Research in the Department of Health Services Administration at the University of Alabama at Birmingham. He is an Associate Director in the UAB Center for AIDS Research and the UAB Center for Outcomes and Effectiveness Research and Education, where he serves as the Director of the Dissemination, Implementation and Improvement Sciences Core. He's currently the Co-Editor of Healthcare Management Review and serves on the editorial board of Medical Care Research and Review and Health Services Research. His research focuses on the antecedents and consequences of organizational changes in healthcare, with special emphasis on dissemination and implementation science in health care. Dr. Hearld, thank you for joining us today.
Patrick SullivanMy pleasure, happy to be here. So I want to start out by talking a little about implementation science. Your manuscript is part of a special issue that Annals has been hosting on implementation science, and I think it's something that a lot of epidemiologists are hearing about but may have variable proximity to. So can you just sort of give us an idea about what implementation science as a field is about, and particularly this idea of organizational context and how that supports the implementation of interventions that have been found to be efficacious, that are evidence-based but need to move into that stage of making it into public health practice?
Larry HearldYeah, that's a great question, so I can give you sort of a what I would consider a more technical definition and then kind of give you some what I think are examples.
Larry HearldI think most people would agree that you know, implementation science is the systematic examination of efforts to get people and organizations to use medicines, therapies, technologies and other types of interventions, as you said, that are known to be effective, that is, they have some kind of evidence base behind them. Organizational context, broadly speaking, refers to the kind of social, political and resource conditions within organizations. Some good and well-known examples of things that I think people think of as organizational context include things like organizational culture and the decision-making structure of organizations. So, for example, does the organization have a flat decision-making structure where most decisions are made at the front lines, or is it a more centralized and hierarchical decision-making structure where organizations are made by top level executives?
Larry HearldAnd the reason that organizational context is so important to consider for implementation science is that many, if not most, evidence-based interventions in healthcare are either directly implemented in healthcare organizations like hospitals or clinics, or are mediated by professionals within these organizations, such as physicians, nurses or social workers. And efforts to implement an evidence-based intervention in organizations typically entail a change in the organizational context by introducing new organizational routines and work processes or modifying existing ones. So I think it's really imperative that implementation science studies consider kind of these existing organizational routines and how these routines will need to be changed to support implementation.
Larry HearldSo that's how I think the field of implementation, science and organizational context go in many ways hand in hand.
Patrick SullivanGreat. So this paper is about one particular academic public health department partnership. Can you talk a little bit about what the goals of that partnership were and how that is sort of depicted in your manuscript?
Larry HearldYeah, so the overarching purpose of our study or goals of our study, which in this case was entitled Coastal, are to increase HIV testing in priority populations, decrease the amount of time it takes to link people who test positive to HIV care, and, of course, decrease time to viral suppression amongst those who are in care. And the way we're approaching this and the way we're trying to do this is by adapting and eventually, or we're currently implementing three Centers for Disease Control evidence-based interventions.
Larry HearldThe first one is this data-driven approach to direct community-based HIV testing in areas with low testing coverage. The second part of the intervention, project Connect, is trying to expedite linkage at the time of diagnosis. And then the third component of this bundled intervention is a rapid antiretroviral therapy start program. A rapid start program. So to understand how to adapt and implement that intervention or those three components of that bundled intervention, one of the first things we wanted to do was to understand in detail the local conditions, that is, the organizational and community context that may require certain types of adaptations, before rolling out these interventions for full-scale use in our local health department that's partnering with us in this work and that is really the focus of the work that was presented in this paper was to kind of present how we approached understanding that context sort of the setting. That was presented in this paper was to kind of present how we approached understanding that context sort of the setting of where we were implementing this intervention in our local health department partner.
Patrick SullivanSo can you walk us through the methods you used in this process and just give a little more detail about how you actually went about this work?
Larry HearldYeah, absolutely so. We began with a, in our case, with a two-day site visit to the county health department that was our partner in this project. So six members of the research team participated in this initial site visit and during the site visit, the research team met with various members of the health department, including the mobile testing team, community outreach team including disease intervention specialists and community health workers, as well as the infectious disease clinical team, and really just kind of asking them to describe their respective work responsibilities and the workflows and how activities were coordinated across these different parts of the organization.
Larry HearldSo, for example, we asked the disease intervention specialist when a person with HIV is referred to you, who is your first point of contact in the clinic? Who do they see after that? And the goal was to get kind of this general understanding of the kind of the layout of the organization, both physically and as well as sort of process-wise and who is involved in different work processes and how these processes were coordinated between people within and across the health department, coordinated between people within and across the health department.
Larry HearldFollowing that site visit we went back, took a bunch of field notes and multiple team members took different field notes and we went back and really consolidated those and used them to construct kind of an initial process map that identified and linked those activities together in sort of a workflow in a sequence.
Larry HearldNext, another research team member visited the health department several months later and observed, with permission of course, different work activities such as linkage to care interviews that were being conducted by disease intervention specialists, observed like new patient appointments for someone that was recently diagnosed with HIV and entering into care for the first time. The research coordinator also kind of conducted more informal observations in different locations like the clinic waiting room and was there really to note things like patient flow in the clinic and observe conversations between staff and as well as staff and patients. But after that we conducted semi-structured interviews 13 interviews, in this case via Zoom, and these interviews were really kind of informed by that provisional process map that we made after the initial site visits and we kind of specifically selected members of the health department teams that were involved in testing linkage in HIV treatment, as well as some of the health department administrators.
Larry HearldKind of the final step in that process was a virtual collaborative process mapping session between the research team and members of the health department implementation team, and this entailed a 60-minute virtual think aloud session where we presented our initial provisional process map. That was based on the initial site visit, those participant observations and interviews, and we essentially asked participants to tell us what did we get wrong by correcting things on the process map in real time. So we used the virtual whiteboard, in this case a mural board. Participants could make those changes themselves or instruct the facilitator to do it, and the end product was this finalized set of processes that describe how a community member may interact with and flow through the health department.
Larry HearldSo that's obviously all in the manuscript where we describe kind of the process of getting to that process map as well as kind of an illustration of that process map.
Patrick SullivanYeah, thanks for that level of detail about how you actually did this, and you sort of mentioned at the end that the sort of key product was this map. You know that talks about how people might move through services. In developing that, what were the key takeaways or lessons learned, or was there anything in that process that you felt like? These are folks, some of your partners are people who live in these environments right, so you're helping them to think about things maybe in a different way. So what were some of the key takeaways that came out of that process that you think might shape how the services are delivered or the impact of them?
Larry HearldYeah, Patrick, great question. I think that also, and I think there are really maybe two takeaways. One, as you point out, I think, from the perspective of the participants, that is, the health department members, I think being able to kind of document and observe how a patient or how a client kind of moves through that process and moves through their organization is really kind of illuminating. It sort of requires them to kind of think about, as well as question, some of the processes that exist in the organization and so I think there's sort of that benefit that exists kind of directly for, in this case our health department partner.
Larry HearldFor me and I think, for us as a research team, one of the key takeaways from this study and I think this is true of a lot of my work in recent years is kind of a recognition of the importance of getting close to your subjects, in this case the health department. I was formerly trained as a management kind of organization scientist. So my training I kind of cut my teeth, so to speak, using large secondary data sets to ask and answer questions about how things like the design and structure of healthcare organizations may affect performance, so things like quality of care and cost of care, but at a very sort of macro level, organizational level, right, and that type of work frequently didn't require me to directly interact with organizations.
Larry HearldSo, something I've come to appreciate more and more as my research career has evolved, including and especially as I've gotten more closely involved in implementation science research, is the importance of getting your hands dirty If you're really going to be effective at implementing things in organizations and studying these things in organizations you really need to get under the hood of these organizations.
Larry HearldIt's not enough to know the make and models, so to speak. You need to understand how it is engineered to run, and this study was fun because it represented one of the most in-depth explorations of an organization, where we were able to apply a lot of different methods to understand how and why things were done in a particular way. So I think that's, for me, really one of the main takeaways from this study, as well as this type of work.
Patrick SullivanGreat and you touched on this a bit, but I think this idea of the multi-method integrated approach and these different ways of trying to understand the organizational function, do you have any other thoughts in general about the strengths or challenges of that kind of a method as you described it?
Larry HearldYeah, certainly. I think the real strength of this type of integrated approach is that it enables researchers to get a more comprehensive picture of the organizational conditions that may support or hinder efforts to implement innovations by combining multiple perspectives and multiple types of data. So much like any mixed or multiple method approach case, however, it was one focused very specifically on understanding the organizational context which, as I mentioned, I think is particularly important when trying to understand how to adapt interventions to those settings and how to implement them.
Larry HearldI also think a strength of this approach is that it was very iterative and cumulative, that is, we were able to incorporate things we learned in previous interactions and data collection activities to inform future interactions with our partners, and I'd like to think that that made the final product really a more accurate depiction of what things actually looked like in the organization. Now, the challenge to this approach, of course, is the time and resources required to conduct such an iterative, multi-method approach to understanding organizational context. So we were fortunate in some ways that we were only doing this with one organization. I'm not sure we would have been able to do it at scale, so I think that's something you'd have to consider for others who are trying to apply this is like- how to balance that need to be deep, but also when you have to try that kind of approach across many different organizations.
Patrick Sullivanhis, and I think that that challenge of sort of breadth and depth is one that's common to many kinds of studies or inquiries that we do, but maybe especially may fall into both the opportunities and the challenges in this kind of approach.
Behind the Paper
Patrick SullivanNow a little bit to a part that we call Behind the Paper, and it's really meant to understand, just for us as people, as scientists, as folks who want to improve health. You know what the personal experience is of doing the different kinds of analyses and work that we do, and here I think the real highlight is about the partnership with the county health department. So can you just talk a little bit about your experience in that partnership with the health department, and how is that the same or different than collaborative models that we might encounter in other kinds of research?
Larry HearldYeah, I think that's a great question, and it's fitting cause I think a lot of the work in this space, both implementation science but also specifically to understanding how to both diagnose and prevent or treat HIV, I think really does embrace this kind of collaborative model or collaborative approach and, as I think many people who do this work would say or recognize, this model of kind of co-production can be really incredibly fruitful in that it does a better job of incorporating the perspectives of the end users, which of course is critical in implementation science. Ultimately, we are trying to kind of support the use of things that we know to be effective by people who will benefit from their use. But it takes time. You have to cultivate and constantly curate relationships with your partners, which means you have to have a certain level of patience, which isn't always easy when you're doing funded research and you have clear kind of milestones and expectations that you need to meet from a funder perspective, but you really can't rush the relationship building process. So because of that you kind of also have to be proactive in your planning when you're doing this type of research.
Larry HearldSo, because if other research activities are contingent upon establishing these relationships, you need to hit the ground running in a study like this or, more realistically, I think these relationships you need to hit the ground running in a study like this or, more realistically, I think these relationships exist prior to implementing the study, perhaps cultivated in the proposal development stage or in previous research studies, but it's difficult to imagine.
Larry HearldYou know, just kind of when we've run into problems with this type of research is when you're trying to build those relationships while also trying to implement a study. That can be really challenging. So in many ways, I think you need to begin a study like this with those relationships already either intact or in development.
Patrick SullivanI appreciate that and I think the whole piece of the relationship here is exactly because each partner is bringing a different set of tools and experiences and organizations that are providing services are understandably focused on the best ways to provide those services to their clients, and so the sort of implementation science process or we might say a research process or this process, is in some tension, right, because it's actually coming in and trying to be a little more systematic and analytical about what folks are doing.
Patrick SullivanSometimes it can feel, I think, for people in the organizations can feel, if not critical, at least that sense of being observed. And so I think that this level of comfort and the shared goals and the reassurance that what comes out of the end of this is meant to help, you know, is meant to reflect back a little bit and help think about how the process might be optimized to promote the organization and the clients. That has to be clear and have that trust throughout, or I think it can otherwise you know be a little bit awkward because of the different perspectives that people are bringing.
Patrick SullivanSo I really appreciate you talking through how you handle that. So I really appreciate this manuscript, which is a different kind of manuscript than we sometimes get at Annals of Epidemiology, but really appreciate you sort of linking it into the idea of how interventions are implemented to make public health impact, and I think that's a critical part of a lot of the articles that we see published need to move through that phase, and so I just want to point out to people who are interested in this topic of implementation science that we currently have an open special issue on the website- there's a special section for it. You can see other manuscripts that relate to implementation science and how they integrate with epidemiology on the website. So I'd encourage folks who want to learn a little more just to look at what else is in the special issue, and I think there are going to be some things that are of interest. That brings us to the end of this episode. Thank you again, Dr. Hearld, for joining us today. It was such a pleasure to have you on the podcast.
Larry HearldMy pleasure. Thank you for having me.
Patrick SullivanI'm your host, Patrick Sullivan. Thanks for tuning in to this episode and see you next time on EPI:Talk, brought to you by Annals of Epidemiology, the official journal of the American College of Epidemiology. For a transcript of this podcast or to read the article featured on this episode and more from the journal, you can visit us online at www. annalsofepidemiology. org. Thank you.
