Chronic disease prevention continues to be inadequate, overall and in achieving health equity, in spite of the many evidence-based practices and policies (EBPPs) available to address risk behaviors such as unhealthful eating, lack of physical activity, and tobacco use. Although clinical settings are needed for EBPPs that involve medical procedures such as immunization or early detection, dissemination of EBPPs can be effective in a variety of settings such as schools and childcare centers, worksites, social service organizations, and religious organizations. More implementation research is needed to meet challenges of effective application of EBPPs in such community settings, in which primary missions, capacity, cultures, and values do not focus on health services delivery. To address health equity, consideration of social and economic contexts of people reached in these settings is essential. This review presents lessons learned from past studies to guide future implementation research and practice across diverse settings and geographies.

Early care and education (ECE) centers are important settings influencing young children’s diet and physical activity (PA) behaviors. To better understand their impact on diet and PA behaviors as well as to evaluate public health programs aimed at ECE settings, we developed and tested the Environment and Policy Assessment and Observation – Self-Report (EPAO-SR), a self-administered version of the previously validated, researcher-administered EPAO. Development of the EPAO-SR instrument included modification of items from the EPAO, community advisory group and expert review, and cognitive interviews with center directors and classroom teachers. Reliability and validity data were collected across 4 days in 3–5 year old classrooms in 50 ECE centers in North Carolina. Center teachers and directors completed relevant portions of the EPAO-SR on multiple days according to a standardized protocol, and trained data collectors completed the EPAO for 4 days in the centers. Reliability and validity statistics calculated included percent agreement, kappa, correlation coefficients, coefficients of variation, deviations, mean differences, and intraclass correlation coefficients (ICC), depending on the response option of the item. Data demonstrated a range of reliability and validity evidence for the EPAO-SR instrument. Reporting from directors and classroom teachers was consistent and similar to the observational data. Items that produced strongest reliability and validity estimates included beverages served, outside time, and physical activity equipment, while items such as whole grains served and amount of teacher-led PA had lower reliability (observation and self-report) and validity estimates. To overcome lower reliability and validity estimates, some items need administration on multiple days. This study demonstrated appropriate reliability and validity evidence for use of the EPAO-SR in the field. The self-administered EPAO-SR is an advancement of the measurement of ECE settings and can be used by researchers and practitioners to assess the nutrition and physical activity environments of ECE settings.

Background: The need for optimal study designs in dissemination and implementation (D&I) research is increasingly recognized. Despite the wide range of study designs available for D&I research, we lack understanding of the types of designs and methodologies that are routinely used in the field. This review assesses the designs and methodologies in recently proposed D&I studies and provides resources to guide design decisions. Methods: We reviewed 404 study protocols published in the journal Implementation Science from 2/2006 to 9/2017. Eligible studies tested the efficacy or effectiveness of D&I strategies (i.e., not effectiveness of the underlying clinical or public health intervention); had a comparison by group and/or time; and used ≥1 quantitative measure. Several design elements were extracted: design category (e.g., randomized); design type [e.g., cluster randomized controlled trial (RCT)]; data type (e.g., quantitative); D&I theoretical framework; levels of treatment assignment, intervention, and measurement; and country in which the research was conducted. Each protocol was double-coded, and discrepancies were resolved through discussion. Results: Of the 404 protocols reviewed, 212 (52%) studies tested one or more implementation strategy across 208 manuscripts, therefore meeting inclusion criteria. Of the included studies, 77% utilized randomized designs, primarily cluster RCTs. The use of alternative designs (e.g., stepped wedge) increased over time. Fewer studies were quasi-experimental (17%) or observational (6%). Many study design categories (e.g., controlled pre–post, matched pair cluster design) were represented by only one or two studies. Most articles proposed quantitative and qualitative methods (61%), with the remaining 39% proposing only quantitative. Half of protocols (52%) reported using a theoretical framework to guide the study. The four most frequently reported frameworks were Consolidated Framework for Implementing Research and RE-AIM (n = 16 each), followed by Promoting Action on Research Implementation in Health Services and Theoretical Domains Framework (n = 12 each). Conclusion: While several novel designs for D&I research have been proposed (e.g., stepped wedge, adaptive designs), the majority of the studies in our sample employed RCT designs. Alternative study designs are increasing in use but may be underutilized for a variety of reasons, including preference of funders or lack of awareness of these designs. Promisingly, the prevalent use of quantitative and qualitative methods together reflects methodological innovation in newer D&I research.

The human papillomavirus (HPV) vaccine is an underutilized cancer control practice in the United States. Although individual contextual factors are known to impact HPV vaccine coverage rates, the impact of macro-level elements are still unclear. The aim of this analysis was to use HPV vaccination rates to explore the underuse of an evidence-based cancer control intervention and explore broader-level correlates influencing completion rates. A comprehensive database was developed using individual-level date from the National Immunization Survey (NIS)-Teen (2016) and state-level data collected from publically available sources to analyze HPV vaccine completion. Multi-level logistic models were fit to identify significant correlates. Level-1 (individual) and level-2 (state) correlates were fitted to a random intercept model. Deviance and AIC assessed model fit and sampling weights were applied. The analysis included 20,495 adolescents from 50 U.S. states and the District of Columbia. Teen age, gender, race/ethnicity, and maternal education were significant individual predictors of HPV completion rates. Significant state-level predictors included sex education policy, religiosity, and HPV vaccine mandate. States with the lowest HPV coverage rates were found to be conservative and highly religious. Little variation in vaccine exemptions and enacted sex and abstinence education polices were observed between states with high and low HPV vaccine coverage suggesting various contextual and situational factors impact HPV vaccine completion rates. Given that gender, religiosity, political ideology, and education policies are predictors of HPV vaccine completion, the interaction and underlying mechanism of these factors can be used to address the underutilization of the HPV vaccine.