Using Implementation Mapping to Develop Implementation Strategies for the Delivery of a Cancer Prevention and Control Phone Navigation Program: A Collaboration with 2-1-1

Abstract

Cancer prevention and control (CPC) behaviors, such as cancer screening, human papillomavirus vaccination, and smoking cessation, are critical public health issues. Evidence-based interventions have been identified to improve the uptake of CPC behaviors; however, they are often inconsistently implemented, affecting their reach and effectiveness. Patient navigation is an evidence-based approach to increasing CPC behaviors. Nevertheless, there are few navigation programs that use systematically developed implementation strategies to facilitate adoption, implementation, and maintenance, which affects uptake and outcomes. This article describes the development of a multifaceted implementation strategy designed to facilitate delivery of a CPC phone navigation program to increase breast, cervical, and colorectal cancer screening; human papillomavirus vaccination; and smoking cessation among 2-1-1 Texas helpline callers. Using implementation mapping, a systematic approach for developing implementation strategies, we designed a strategy that involved training 2-1-1 information specialists to deliver the program, developed online tracking and quality-monitoring (audit and feedback) systems, and developed and distributed protocols and other materials to support training and implementation. Through this iterative process and our collaboration with 2-1-1 Texas call centers, our project resulted in a comprehensive training program with a robust curriculum of pertinent program content, for which we identified core components and appropriate delivery modes that are culturally relevant to the population. The results of this study can be applied to the development of more systematic, transparent, and replicable processes for designing implementation strategies. The study also demonstrates a process that can be applied to other contexts and other CPC program implementation efforts.

Background/Introduction

Cancer prevention and control (CPC) behaviors, such as cancer screening, HPV vaccination, and smoking cessation, are critical public health issues. These behaviors can help to reduce cancer morbidity and mortality through early detection. Evidence-based interventions (EBIs) have been identified to improve the uptake of CPC behaviors (Community Preventive Services Task Force, 2014, 2016a, 2016b, 2016c); however, they are often inconsistently implemented, affecting their reach and effectiveness (Brownson, Tabak, Stamatakis, & Glanz, 2015; Walker et al., 2018).

Patient navigation is a service that connects patients to cancer control services as a means to address patient-level psychosocial and access barriers (Wells et al., 2008). Patient navigation has been investigated as an approach to increasing CPC behaviors. Findings from multiple studies suggest that it can improve cancer screening rates and increase the proportion of people who seek follow-up services (Freund et al., 2014; Paskett, Harrop, & Wells, 2011; Robinson-White, Conroy, Slavish, & Rosenzweig, 2010; Rodday et al., 2015; Wells et al., 2008). Notably, patient navigation has been particularly effective among medically underserved populations, racial/ethnic minorities, and those with the greatest number of barriers (Freeman, Muth, & Kerner, 1995; Freund et al., 2014; Jandorf, Gutierrez, Lopez, Christie, & Itzkowitz, 2005; Lasser et al., 2011; Robinson-White et al., 2010; Rodday et al., 2015). Despite the effectiveness of patient navigation, disseminating and implementing such programs in real-world settings is challenging. This may be due, in part, to there being few navigation programs that use systematically developed implementation strategies to facilitate their adoption, implementation, and maintenance (Freund, 2017; Robinson-White et al., 2010), especially in community and social service settings (Brownson, Baker, Deshpande, & Gillespie, 2017; Burgio, 2010; Highfield, Bartholomew, Hartman, Ford, & Balihe, 2014). Thus, there is a critical need to develop and test implementation strategies that facilitate the delivery of patient navigation programs in community, clinical, and social service settings.

Implementation strategies are techniques used to improve adoption, implementation, maintenance, and scale-up of interventions (Powell et al., 2012; Proctor, Powell, & McMillen, 2013). They can include trainings, protocols, systems, and other means that are designed to facilitate the uptake and use of clinical or behavioral interventions. These strategies are essential to achieving intended results and reducing the gap between EBI development and its sustained use in real-world settings.

Methods have been proposed to inform the development and use of implementation strategies to support program delivery in various settings (Powell et al., 2017). One such method is Implementation Mapping, a systematic approach to developing or selecting and tailoring implementation strategies through five main tasks (Fernandez et al., 2019). It was developed based on the Intervention Mapping framework (a six-step process that guides the development of scientifically based health intervention programs, using community stakeholder input, behavioral theories, and empirical findings) (Bartholomew-Eldredge et al., 2016), but expands on the implementation planning component of Intervention Mapping (Step 5) by incorporating guidance from the implementation science field (Fernandez et al., 2019).

In a unique partnership between a community-based service agency, 2-1-1 Texas, and an academic institution, the Center for Health Promotion and Prevention Research (CHPPR) at The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, a CPC phone navigation program was developed to increase breast, cervical, and colorectal cancer screening, HPV vaccination, and smoking cessation among 2-1-1 Texas helpline callers in need of CPC services.

2-1-1, a service partly funded by the Health and Human Services Commission, is a nationally designated, confidential telephone service that connects callers to basic health and social services within their communities at no cost. 2-1-1 Texas is the largest 2-1-1 helpline in the US, divided into 25 regions, each covered by an area information center (AIC) (United Way 2-1-1 Texas, n.d.; United Way Houston, n.d.). Trained, nationally certified information specialists provide 24-hour-per-day coverage to callers, using a comprehensive database of services offered by community-based, government, and nonprofit agencies. These call centers vary in size but have the same purpose to provide their callers with the most relevant referrals and information for their circumstances and needs, including food, housing, rent/mortgage, utility assistance, health related needs, child care, substance use treatment, and crisis counseling; in 2019, they served a total of 1,325,200 callers (United Way Houston, n.d.). As do most 2-1-1 call centers in the United States, 2-1-1 Texas centers serve primarily low-income and minority populations in need; thus, they are well positioned to implement patient navigation for CPC behaviors to medically underserved populations across Texas.

The goal of the program was, first, to add CPC resources (e.g., screening, vaccination, treatment, cessation services) to 2-1-1’s extensive referral database and, second, to equip 2-1-1 information specialists to assess cancer control needs and provide support beyond their standard referrals (i.e., name and contact information of service/resource). The purpose of this paper is to describe the development of a multifaceted implementation strategy, using Implementation Mapping, to facilitate delivery of the CPC phone navigation program.

Methods

In partnership with three 2-1-1 Texas call centers (AICs based in Houston, Weslaco, and El Paso), UTHealth researchers developed a phone navigation program that added CPC resources to 2-1-1 Texas’ referral database to connect callers in need of breast, cervical, or colorectal cancer screening, HPV vaccination, or tobacco cession to appropriate services. To implement the new navigation component, 2-1-1 information specialists needed to assess cancer control needs among callers and inform them of the importance of adhering to relevant CPC behaviors as well as provide logistical support (e.g., scheduling appointments, arranging transportation to care), and increase motivation by addressing both psychosocial and structural barriers. We designed a multifaceted implementation strategy to facilitate the implementation of the program.

Implementation Mapping: Planning Program Adoption, Implementation, and Sustainability

Implementation Mapping is an iterative implementation planning process that guides researchers and program planners through a systematic list of tasks to produce a comprehensive implementation plan (Fernandez et al., 2019) and was used to design the multifaceted implementation strategy. The tasks include conducting an implementation needs assessment and identifying program implementers (Task 1); stating implementation outcomes and performance objectives (implementation behaviors), identifying determinants (both internal and environmental/organizational), and creating matrices of change objectives (Task 2); choosing theoretical methods and designing implementation strategies (Task 3); producing implementation protocols and materials (Task 4); and evaluating implementation outcomes (Task 5). Through these tasks, program planners can develop strategies for three stages of program use: adoption, implementation, and maintenance. Program planners develop matrices with performance objectives for each stage, and each performance objective is linked to behavioral determinants that inform change objectives. Change objectives are then used to create a theory-informed blueprint for the adoption, implementation, and sustainability of the program.

For this project, study staff planned to implement the CPC phone navigation program through three 2-1-1 Texas call centers, which previously agreed to adopt the program. The results presented below concern the process for developing strategies to enhance implementation (Tasks 1–4) as well as evaluating implementation and the multifaceted implementation strategy (Task 5). While iterative over the course of the four-year project period, the main implementation planning activities took approximately six to eight months to complete and was led by an implementation planning group consisting of UTHealth CHPPR researchers (principal investigator of the project, co-investigators, project manager, and graduate research assistant), the 2-1-1 Texas Director, and the Houston AIC call center manager.. The implementation planning group held 4, two-hour brainstorming sessions to inform the various tasks followed by several communications via telephone and email to finalize implementation decisions. This planning process is described in detail below.

Results

Task 1: Conduct an Implementation Needs Assessment and Identify Program Implementers

Prior to the start of the study, UTHealth researchers and 2-1-1 Texas conducted a pilot study to test the feasibility of implementing the proposed navigation program among 2-1-1 callers in Houston. A brief cancer risk assessment (offered in English and Spanish) was administered to callers, using the protocol to be used in the current study. Study staff also examined the capacity of the 2-1-1 call center to assess cancer control needs among callers and to make recommendations for services. This assessment revealed a need to improve 2-1-1- staff knowledge about current CPC recommendations and skills to educate callers about CPC services.

This preliminary work helped to inform who should be involved in the implementation of the navigation program (i.e., key stakeholders). The implementation planning group (hereafter “we”) held an initial two-hour brainstorming session to answer the following key questions: (1) “Who will implement the program?” and (2) “Will the program require different people to implement different components?” We determined that 2-1-1 information specialists would be the primary program implementers. Information specialists recruited to participate in the study would fulfill one of two roles: (1) cancer specialists, who would conduct a comprehensive cancer risk assessment of 2-1-1 callers’ needs for CPC services and provide relevant referrals; and (2) cancer control navigators, who would follow up in regard to the referral and provide navigation services. We determined that call center managers recruited to participate in the study would support implementation in a supervisory role by managing the call-tracking and quality-monitoring systems and providing on-site support to cancer specialists and navigators.

Task 2: State Implementation Outcomes and Performance Objectives, Identify Determinants, and Create Matrices of Change Objectives

The next task of Implementation Mapping was to determine program implementation outcomes and identify who would have to do what to achieve these outcomes. To identify implementation outcomes, we answered the question: “What do program implementers have to do to implement the essential program components?” To deliver the CPC phone navigation program, we determined that both cancer specialists and cancer control navigators need to assess 2-1-1 callers’ need for CPC services (i.e., conduct the comprehensive cancer risk assessment) as well as inform those in need of services about CPC recommendations and refer them to CPC services. In addition, cancer control navigators need to motivate callers to obtain relevant CPC services and support them in overcoming barriers. We then discussed what the cancer specialists and navigators would need to do to accomplish each of these outcomes. This process informed the identification of performance objectives (subtasks) for each of the implementation outcomes (Table 1).

Table 1.

Sample Implementation Outcome with Corresponding Behavioral Determinants, Performance Objectives, and Change Objectives

Implementation outcome: Cancer control navigators will refer eligible 2-1-1 callers to relevant cancer prevention and control (CPC) services
	Behavioral Determinants
Performance Objectives	Knowledge	Self-Efficacy	Skills	Attitudes	Outcome Expectations
	Change Objectives
PO.1. Provide callers with current CPC recommendations and prevention guidelines for breast, cervical, and colorectal cancers	K.1a. List screening recommendations for breast, cervical, colorectal, and lung cancers K.1b. Describe risk factors related to breast, cervical, and colorectal cancers K.1c. State at least two personal actions that can reduce risk for breast, cervical, and colorectal cancers	SK.1. Express confidence in clearly describe screening methods for breast, cervical and colorectal cancers, HPV vaccination, and smoking cessation treatment	SK.1. Demonstrate the ability to clearly describe screening methods for breast, cervical and colorectal cancers, HPV vaccination, and smoking cessation treatment
PO.2 Assist eligible callers in finding low-cost CPC services	K.2a. Explain how to locate CPC resources for callers based on their demographic profile (e.g., gender, age, insurance, income, citizenship) and geographic location K.2b. List ways of verifying information about CPC resources K.2c. Describe protocol for contacting facilities for clarification or additional information K.2d. State limits for referring callers within the scope of this project K.2e. State additional resources for more information about other cancers (such as www.texascancer.info or 1-800-4-CANCER [1800-422-6237])	SE.2a. Express confidence in using Refer Net and Qualtrics to find, e.g., information, prepare reports, transfer data. SE.2b. Express confidence in following scripts and other protocol materials for referring callers to relevant resources	SK.2a. Demonstrate ability to use Refer Net and Qualtrics to find, e.g., information, prepare reports, transfer data. SK.2b. Demonstrate ability to follow scripts and other protocol materials for referring callers to relevant resources	ATT.2. Feel that the role of a navigator is to refer callers	OE.2. Expect to make a difference and save lives with referral to low-cost CPC sites
PO.3. Assist eligible callers in navigating through the health care system	K.3a. Identify common barriers associated with access to cancer screening and prevention K.3b. List some strategies for assisting callers to overcome barriers to obtaining recommended cancer control services K.3c. Describe what callers can do to be better prepared for entering the health care system (specifically in terms of cancer screening/ prevention) i.e. income documents, identification, etc.	SE.3. Express confidence in following scripts and other protocol materials for assisting callers in navigating through the health care system	SK.3. Demonstrate ability to follow scripts and other protocol materials for assisting callers in navigating through the health care system
PO.4. Communicate with study participants respectfully	K.4a. Describe effective ways of building rapport with callers K.4b. Identify general guidelines for cordial, respectful conversations with callers and agency personnel even during difficult situations and/or minor conflicts (issue resolution, behavioral change facilitation)	SE.4. Express confidence in using non-judgmental tone while discussing personal matters with study participants	SK.4. Demonstrate ability in using non-judgmental tone while discussing personal matters with study participants

Next, we specified determinants of program implementation. We held a brainstorming session to generate a list of facilitators and barriers to implementation, taking into consideration the performance objectives. UTHealth researchers subsequently reviewed available literature and conducted one-on-one phone interviews with information specialists and the Houston call center manager and Director to identify additional factors that influence implementation. We then held a second brainstorming session to review the generated list and prioritize determinants based on the strength of their association with implementation of the navigation program (importance) and their changeability. For example, we determined that knowledge, skills/self-efficacy, attitudes, and outcome expectations related to connecting 2-1-1 callers to CPC services were important and changeable determinants. A matrix for each implementation outcome was generated, with performance objectives listed in rows to the left and the final determinants added as column headings. Table 1 presents a sample matrix for the implementation outcome, select corresponding performance objectives, and relevant determinants.

We identified change objectives for each determinant and performance objective. Change objectives concerned what needs to change in the determinants to accomplish the associated performance objective. Changes in these determinants are expected to drive achievement of the performance objectives and influence specified outcomes. We asked the following questions to inform the development of change objectives: (1) “Why would an implementer perform the performance objective?” and (2) “What would need to change related to a specific determinant for an implementer to do the related performance objective?” Example change objectives are included in the sample matrix presented in Table 1. The full matrix of change objectives identified during Task 2 became the blueprint for the development of implementation strategies to enable delivery of the CPC phone navigation program. In combination with Task 1, this task took approximately one month to complete.

Task 3: Select Theoretical Methods and Design Implementation Strategies

The next task was to select methods (or techniques) that would create change in the determinants identified. Change methods are the mechanism of action or logic about what influences the determinants of implementation and form the key ingredients of the strategy. Implementation strategies (referred to as “practical applications” in Intervention Mapping) operationalize the selected methods. During study meetings with the PI and Co-Is we generated a list of proposed change methods and strategies, taking into consideration the matrices of change (Table 1). UTSPH researchers reviewed previous research on effective methods and strategies as well as theoretical frameworks in both behavioral (social cognitive theory) and implementation science (diffusion of innovation) to address specific determinants and consulted with 2-1-1 managers on their feasibility. We then organized change objectives based on the identified determinants and selected activities that would help to fulfill them. For example, as described in the sample matrix presented in Table 2, for the performance objective, “assist eligible callers in finding low-cost CPC services,” its associated change objective, “demonstrate ability and confidence in following scripts and other protocol materials for referring callers to relevant resources,” relates to skills and self-efficacy as found in the behavioral capacity construct of social cognitive theory. Methods for fulfilling this change objective include providing information and guided practice. We identified the following as feasible approaches to operationalizing the selected methods: PowerPoint presentations with discussion that focus on navigation protocols and practices (providing information), small-group role playing in which navigators complete a mock navigation activity, and receive constructive feedback (guided practice). Adult learning theory, social learning, and cognitive behavioral approaches (e.g., guided practice for identifying and overcoming barriers to program implementation) informed our selection of methods. In addition, we emphasized active learning methods, using a variety of theory-based strategies (e.g., role playing).

Table 2.

Sample Change Objective with Corresponding Methods and Practical Applications

Implementation outcome: Cancer control navigators will refer eligible 2-1-1 callers to relevant cancer prevention and control (CPC) services
Change Objective	Determinants (Theory)	Methods	Practical Applications (Implementation Strategies)	Implementation Strategy Component
K.1a. List screening recommendations for breast, cervical, colorectal, and lung cancers	Knowledge (Social cognitive theory)	Providing Information Visual Cues	PowerPoint presentation slides Cubicle posters Common barriers and strategies handout	Training in cancer control Manuals, protocols, and other supplementary materials
SE/SK.2b. Express confidence and demonstrate ability to follow scripts and other protocol materials for referring callers to relevant resources	Self-efficacy and skills (Social cognitive theory)	Providing Information Guided Practice	PowerPoint presentation slides Small-group role playing	Training in cancer control Manuals, protocols, and other supplementary materials
K.3b. List some strategies for assisting callers to overcome barriers to obtaining recommended cancer control services	Knowledge (Social cognitive theory)	Providing Information Guided Practice	PowerPoint presentation slides Small-group role playing Manuals and Protocols	Training in cancer control Manuals, protocols, and other supplementary materials
SE/SK.4. Express confidence and demonstrate ability in using non-judgmental tone while discussing personal matters with study participants	Self-efficacy and skills (Social cognitive theory)	Providing Information Guided Practice	PowerPoint presentation slides Small-group role playing	Training in cancer control Manuals, protocols, and other supplementary materials

The compilation of methods and discrete implementation strategies generated during Task 3 informed the design of the multifaceted implementation strategy, which involved (1) ongoing training with 2-1-1 information specialists, along with training modules and other supplementary materials; and (2) online tracking and quality monitoring (audit and feedback) systems, along with manuals and protocols produced to support implementation.

Task 4: Produce Implementation Protocols and Materials

The final task for developing the multifaceted implementation strategy to deliver the CPC phone navigation program was to design the actual training, online tracking and quality monitoring systems, and associated protocols and materials. We held a brainstorming session to discuss how selected methods and strategies would be put in place and the materials needed to support implementation. In combination with Task 3, Task 4 took approximately four to six months to complete. The two components of the multifaceted implementation strategy are discussed below.

Component 1: Training in cancer control.

The standard 2-1-1 training for all information specialists included information on 2-1-1 protocols, computer system software, telephone system, referral database, documentation requirements, referral, crisis intervention, mental illness, and special needs populations. In addition, the information specialists are certified by the Alliance of Information and Referral Systems (AIRS), which provides documentation of their ability in the area of information and referral (O’Shea & King, 2004). To supplement typical 2-1-1 training, information specialists involved in the study (cancer specialists and cancer control navigators) received training on changes to their standard training, developed by the Houston 2-1-1 manager. They also received project-specific training to conduct cancer risk assessments and provide CPC-related referrals to callers.. The modules covered a variety of topics, including cancer-related disparities by demographic factors; current CPC recommendations and methods; barriers to performing recommended CPC behaviors; study objectives, protocols, and processes; research ethics; roles and responsibilities as a cancer specialist or navigator; effective communication; and cultural and linguistic competency.

A one-day training was conducted for cancer specialists and call center managers, and an additional two-day training was conducted for cancer control navigators. The expanded training provided more attention to cancer prevention, building rapport with callers, understanding callers’ perceptions of and reasons for considering a CPC service, understanding cultural differences, and correcting misinformation about specific CPC services. In addition, navigators received training in motivational interviewing and problem solving (MAPS) by professional trainers from M.D. Anderson Cancer Research Center. MAPS is an evidence-based behavior change approach to facilitating behavior change that utilizes a combined motivational enhancement and problem-solving approach based on motivational interviewing (Miller & Rollnick, 1991, 2005) and social cognitive theory (Bandura, 1986; Marlatt & Donovan, 2005; Witkiewitz & Marlatt, 2004). This in-depth training served to enhance navigators’ skills and effectiveness in supporting and motivating callers to obtain relevant CPC services.

We developed training schedules and outlines to guide implementation of the above trainings; a series of PowerPoint presentations to facilitate didactic and interactive discussions, group work, case studies, mock research reviews, games, and other activities during the training; handouts to supplement training presentations and activities; and other interactive tools to engage participants during the training and facilitate implementation (e.g., bilingual informational posters (visual cues) for cancer specialists and navigators’ workspace). We also developed manuals of procedures for cancer specialists and navigators to guide their implementation of the program, and M.D. Anderson provided a MAPS training manual. Print versions of all training materials were included in a training binder for participants to refer to during and after the training.

Component 2: Tracking and quality monitoring (audit and feedback) systems.

We developed an online survey tool in English and Spanish, using Qualtrics, to assess whether a 2-1-1 caller was in need of cervical, colorectal, or breast cancer screening, the caller or his or her child needed the HPV vaccine, or the caller was in need of smoking cessation treatment (risk assessment). The survey tool also was used to collect basic demographic information, psychosocial determinants, and CPC service completion at follow-up. We also developed a system that would help track each caller who completed the risk assessment through to their 3-month follow-up call. Cancer specialists and navigators were able to access, discuss, and update information in real time by using a secure online project management database system (SmartSheet) which was needed to supplement capabilities of the 2-1-1 computer referral software (ReferNet/CommunityOS). While this required maintenance of three data capture systems, over time the process ran seamlessly, enabling the project to work in three sites simultaneously and minimizing differences in the tracking and documentation protocols.

When a 2-1-1 caller agreed to participate in the risk assessment, a cancer specialist would enter the caller’s data into Qualtrics, create a contact in the 2-1-1 referral system, and then enter the caller’s data into the Smartsheet tracking tool. After being assigned a caller in need of services, the cancer control navigator was responsible for documenting the case, which included initial and follow-up calls, content of the calls, CPC service needs and barriers, plans of action, mailing of educational materials, appointment information and reminders, insurance information, and outcome of cancer control service. We developed manuals and protocols as guidance for conducting risk assessments and providing navigation services.

Complementary to the call tracking system, we implemented a quality monitoring (audit and feedback) system to monitor and ensure the quality of the referrals and navigation services provided to 2-1-1 callers. Existing 2-1-1 quality assurance protocols mandated a minimum of six calls monitored per specialist each quarter. Call center managers used the Cisco Supervisor software to listen in on or record incoming calls and then provide feedback. We adapted existing monitoring protocols, but increased the number of calls monitored to approximately one call per specialist per day. Call center managers or study staff at UTHealth scheduled follow-up meetings with cancer specialists and navigators to provide feedback, topics of concern were addressed at/or retrained during weekly project meetings.

Task 5: Evaluation of Implementation Outcomes

Task 5 of Implementation Mapping guided our plans to evaluate the implementation and effectiveness of the strategy. This process took approximately one month and began with writing evaluation questions and developing indicators and measures for assessment. We identified the following questions: (1) did the multifaceted implementation strategy respond to program implementers’ needs for delivering the CPC phone navigation program (“acceptability,” as indicated by implementers rating the implementation strategy components as satisfactory), and (2) did program implementers deliver the CPC phone navigation program as intended (“fidelity,” as indicated by implementers meeting quality expectations).

To assess acceptability, we developed a 12-question training satisfaction survey. It was administered at the end of each training session and assessed satisfaction with the training content, using a 4-point scale (1 = strongly agree, 2 = agree, 3 = disagree, 4 = strongly disagree). To assess implementation fidelity and ascertain quality execution of protocols, we developed a performance checklist. It included quality indicators related to cancer specialists and navigators’ interaction with callers, call management, service provision (i.e., referral, navigation), and documentation and was assessed using a 3-point scale (0 = unacceptable/two or more criteria not met, 1 = needs improvement/any one criteria not met, 2 = meets expectations). In addition, research staff documented general comments about fluency, pace, time management, and level of comfort/familiarity with scripts, terms, overall content, and protocols/processes. Call center managers or study staff at UTHealth also reviewed call tracking documentation to monitor cancer specialists and navigators’ activities (e.g., number of callers referred or navigated to CPC services, timeliness of follow-up) and met with them bi-weekly to ensure appropriate implementation.

To get a better understanding of factors proximal to fidelity, we also assessed implementers’ knowledge and skills required to perform expected duties. We developed a 40-question training assessment that covered the main concepts within the training. It included parameters to assess knowledge acquisition and changes in determinants (i.e., self-efficacy, attitudes, and outcome expectations) related to the performance and change objectives. Knowledge questions were multiple choice and organized by module. Self-efficacy was assessed using an 11-point scale (0 = not at all confident, 5 = moderately confident, 10 = very confident), and attitudes and outcome expectations were assessed using a 4-point scale (1 = strongly agree, 2 = somewhat agree, 3 = somewhat disagree, 4 = strongly disagree).

Over the course of the four-year project period, we trained a total of 11 cancer control navigators (5 in Houston, 5 in Weslaco, and 1 in El Paso) and 47 cancer specialists (40 in Houston, 3 in Weslaco, and 4 in El Paso). Overall, participants were satisfied with the training, and assessment results indicated an improvement in knowledge, skills, self-efficacy, attitudes, and outcome expectations. Cancer specialists and navigators expressed confidence in their knowledge and ability to motivate, assist, and follow up with 2-1-1 callers regarding breast, cervical, and colorectal cancer screening, HPV vaccination, and smoking cessation. The quality monitoring, however, did call for an increased focus on continuing education. We found that booster sessions were needed to aid in keeping knowledge and skills up to date. Given that implementation of the navigation program occurred over a four-year period, these booster sessions (informed by evaluation results, audit and feedback sessions, and commonly asked questions) were helpful in providing continual professional education, such as keeping cancer specialists and navigators up to date on recommendations, providing additional information about CPC resources, reviewing motivational interviewing skills, and generally feeling knowledgeable and comfortable administering the risk assessment or providing navigation.

Discussion

Although the goal of a health promotion program is to encourage health behavior change among program participants, successful implementation of the program also requires behavior change among program implementers (Bartholomew-Eldredge et al., 2016). The Intervention Mapping framework has been effective in the development and adaption of a variety of health promotion programs (Bartholomew-Eldredge et al., 2016), including those related to cancer prevention and control (Fernández, Gonzales, Tortolero-Luna, Partida, & Bartholomew, 2005; Forbes et al., 2012; Highfield et al., 2015; Scarinci, Bandura, Hidalgo, & Cherrington, 2012; Vernon et al., 2011). It is also a powerful tool for planning the implementation of health promotion programs (Bartholomew-Eldredge et al., 2016; Powell et al., 2017) through a structured and collaborative process, specifically Intervention Mapping Step 5 (now conceptualized as Implementation Mapping). Implementation Mapping has been identified as a promising approach to selecting and tailoring implementation strategies to a specific context (Fernandez et al., 2019; Powell et al., 2017) and has been used to develop other implementation strategies (Donaldson & Poulos, 2014; Highfield, Valerio, Fernandez, & Bartholomew-Eldridge, 2018). In this study, it was used to develop a multifaceted implementation strategy that would facilitate the delivery of a CPC phone navigation program to increase breast, cervical, and colorectal cancer screening, HPV vaccination, and smoking cessation among 2-1-1 Texas callers.

The Implementation Mapping process led to a multifaceted implementation strategy that consisted of individual- and organizational-level components, including conducting ongoing training with 2-1-1 information specialists; developing online tracking and quality monitoring (audit and feedback) systems; and developing and distributing culturally appropriate educational materials, manuals, and protocols to facilitate training and implementation. The literature suggests that using a multifaceted implementation strategy can lead to improved implementation outcomes (Baker et al., 2010; Kirchner, Waltz, Powell, Smith, & Proctor, 2017; Powell et al., 2017; Rogal et al., 2017). In a study that reviewed implementation strategies for mental health interventions, a combination of discrete strategies, including ongoing training, educational materials, and quality monitoring tended to demonstrate positive effects in comparison to single, more passive implementation strategies, e.g., training or education materials alone (Powell, Proctor, & Glass, 2014).

Using a multifaceted implementation strategy will not guarantee success; however, many of the strategy components included in our study have been found to be effective in previous research. For example, one study found that ongoing training and fidelity monitoring were necessary to achieve successful implementation of child and adolescent mental health interventions (Novins, Green, Legha, & Aarons, 2013). In addition, Zwerver, Schellart, Knol, Anema, and van der Beek (2011) found that an educational/training-focused implementation strategy developed using Implementation Mapping (Zwerver, Schellart, Anema, Rammeloo, & van der Beek, 2011) was effective in improving physicians’ implementation of guidelines for depression. Further, there is consensus among implementation science experts that conducting ongoing training, developing and distributing educational materials, developing and organizing quality monitoring systems, developing and implementing tools for quality monitoring, and auditing and providing feedback are highly important and feasible implementation strategies (Waltz et al., 2015).

The use of Implementation Mapping provided a structured, iterative approach to implementation planning. It is recommended as a useful approach because it is collaborative in nature (Powell et al., 2017), which is critical to implementation (Chambers & Azrin, 2013). It was particularly beneficial for our initiative, as our community partners were able to comprehend the logical flow from program development through to implementation planning and how it resulted in the outcome of reaching the priority population and promoting CPC behaviors. Implementation Mapping also addresses the need for more systematic, transparent, and replicable processes for developing or selecting and tailoring implementation strategies (Bosch, Van Der Weijden, Wensing, & Grol, 2007; Powell et al., 2017) and takes into account the complexity of implementation (Chao, 2007) by considering multi-level factors (Powell et al., 2017).

Specific to developing implementation strategies for 2-1-1 call centers across the United States, several considerations should be noted. For example, data collection methods and capacities may differ across the 2-1-1 centers; thus, an implementation strategy developed for one location may not be applicable for another. It is thus important to tailor strategies to the context. An additional consideration of the use of Implementation Mapping is that it may require that community partners and project personnel are trained on how the process works. When using Implementation Mapping with a community organization, particularly a service-oriented one, there may be a need to familiarize partners with relevant terms and theories or to describe them in a way that those unfamiliar with Implementation Mapping can understand. Notably, the detailed, systematic layout of each planning task can easily facilitate this process. Courses and intensive seminars in Intervention Mapping and Implementation Mapping can be beneficial to public health professionals with limited expertise in this area.

Conclusions

Through the iterative processes of Implementation Mapping and our collaboration with 2-1-1 Texas, our project resulted in a comprehensive training program with a robust curriculum of pertinent program content that facilitated the delivery of a CPC phone navigation program. In addition, we identified core components and appropriate delivery modes culturally relevant to the priority population. The results of this study can be applied to the development of more systematic, transparent, and replicable processes for designing implementation strategies. The study also demonstrates a process that can be applied to other contexts and other cancer prevention and control program implementation efforts.