Understanding mechanisms of multi-level implementation strategies for autism interventions in a randomized trial across service systems.

BACKGROUND: Understanding the effectiveness of implementation strategies to support uptake of evidence-based interventions (EBIs) requires examining activation of mechanisms targeted by implementation strategies. This study uses data from the TEAMS (Translating Evidence-Based Interventions for Autism) hybrid type III implementation-effectiveness trial to examine whether leader-level and provider-level implementation strategies, when paired with provider training in AIM HI (An Individualized Mental Health Intervention for Autism) in mental health programs (Study 1) and CPRT (Classroom Pivotal Response Teaching) in schools (Study 2) successfully activated proposed implementation mechanisms (3 for leader level strategy and 2 for the provider-level strategy). We also examined whether any of the identified mechanisms associated with the leader-level strategy mediated the previously reported effect of the strategy on implementation and child outcomes. METHODS: Organizations were randomized to receive a leader-level strategy (TEAMS Leadership Institute [TLI]), provider strategy, both strategies, or neither strategy (EBI provider training only). Leader participants were recruited from enrolled programs/districts and then supported recruitment of provider/child dyads. Children ranged in age from 3 to 13 years. The combined sample included 65 programs/districts, 95 TLI leaders, and 385 providers/child dyads. Multi-level modeling was used to test hypotheses. The hypothesized mechanisms were implementation leadership, implementation climate, and implementation support strategies for TLI and EBI attitudes and motivation for training for TIPS. RESULTS: The leader-level strategy engaged the most proximal of the three hypothesized mechanisms (implementation support strategies). The provider-level intervention did not engage any of the hypothesized mechanisms. There was an interaction between the leader-level and provider-level strategies on implementation climate and provider motivation mechanisms favoring groups that received both implementation strategies compared to those that only received the provider-level strategy. No mechanisms significantly mediated the effect of the leader-level strategy on implementation or clinical outcomes. CONCLUSIONS: This study provides support that a brief implementation leadership and climate training, TLI, increases leader use of specific actions to promote autism EBIs across two public service systems, children's mental health and public education. This does not fully account for strategy effects on fidelity or clinical outcomes. Findings advance the study of implementation mechanisms by examining how leadership training might work and identifying a clear need to focus on leader-level implementation strategies in these systems of care. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03380078.