A mixed methods evaluation of mechanisms for facilitation in pediatric primary care

BACKGROUND: Understanding how implementation strategies work is vitally important for the deployment of evidence-based practices (EPBs) in healthcare settings. Specifically, mechanistic inquiry provides information on specific targets (e.g., buy-in, saliency) that must be engaged for a strategy to be successful. We used mixed-methods to investigate mechanisms of facilitation as part of a trial to implement S.A.F.E. Firearm, a brief evidence-based practice which includes firearm storage counseling and offering free cable locks in pediatric primary care during well-child visits. METHODS: We used a mixed-methods approach to ascertain mechanisms. Quantitative analyses determined whether clinic-level adaptive reserve (e.g., mechanism) mediated the impact of facilitation (e.g., strategy) on reach (e.g., primary outcome). Adaptive reserve, evaluated via clinician survey, refers to a clinic's ability to broadly make and sustain change and includes multiple components (i.e., relationship infrastructure, facilitative leadership, sensemaking, teamwork, work environment, and culture of learning). Importantly, adaptive reserve is not the specific capacity to implement a given EBP. Second, qualitative interviews guided by the updated Consolidated Framework for Implementation Research, and analyzed using deductive and inductive approaches, were conducted with pediatric clinicians, clinic change agents, and health system leaders to ascertain other mechanisms. Mixed methods integration occurred at completion of both activities. RESULTS: Quantitative analyses indicated that adaptive reserve did not mediate the effect of facilitation on reach. Qualitative findings illustrated other potential mechanisms of facilitation including: increasing buy-in and saliency to help overcome initial inertia and to support application of training principles in practice; strong collaborative relationships between facilitators and clinics to improve accountability; in-person visits or electronic communications that serve as reminders; reinforcing the why and how of the intervention (sensemaking); and fostering team collaboration to troubleshoot logistical barriers. DISCUSSION: While prior studies have found that adaptive reserve was related to facilitation, our mediation analysis did not support this hypothesis. Contextual factors may offer potential explanations, particularly a lower-intensity facilitation in this context commensurate with a smaller practice change (e.g., a brief program intended to take < 1 min), but further study is needed. Our qualitative results offer a potentially new mechanistic model of facilitation to be investigated in future studies.