When Research Is a Barrier: Challenges of Implementing Evidence-Based Interventions in the Context of a Randomized Clinical Trial

Introduction: Child welfare systems throughout the U.S. are adopting evidence-based interventions (EBIs) for in-home parenting services with varying success. The instantiation of EBIs in these systems entails a complicated process for the organizations and individuals tasked with their delivery. This process demands balancing multiple factors associated with both (a) the inner context of the implementing organizations (e.g., organizational culture, scopes of work, and EBI support from leadership) and individual practitioners (e.g., openness to innovation, readiness for change, caseloads, perceptions of client needs) and (b) the outer context of the broader system in which implementing organizations operate (e.g., circumstances surrounding funding, procurement and contracting, and legislative mandates).

Methods: We conducted in-depth interviews and focus groups with child welfare professionals in four states. These were individuals responsible for delivering in-home parenting services as part of a longitudinal clinical trial of SafeCare^®, an EBI to prevent child maltreatment. Through purposive sampling, we recruited a total of 22 program administrators, 26 supervisors, and 83 frontline staff across nine organizational sites that had enrolled in the clinical trial. Our iterative qualitative analysis approach combined open- and focused-coding techniques to examine inner- and outer-context factors affecting implementation and outcomes of SafeCare.

Results: Our findings point to key factors enabling SafeCare implementation when present or engendering barriers when absent, including shared vision and sustained buy-in regarding SafeCare across system and organizational levels, ongoing leadership support, and encouragement from outer-context stakeholders (e.g., funders) to adopt EBIs. Barriers often emanated from outer-context upheavals that diverted organizational and provider foci away from SafeCare, insufficient preparation by system and organizational leaders to integrate SafeCare into contracts, policies, and procedures, and a lack of familiarity among administrators, supervisors, and home visitors with EBI implementation requirements. Qualitative data also reveal that the requirements of the research study itself constituted a substantial barrier to successful SafeCare implementation as child welfare professionals struggled to integrate activities related to recruitment and randomization into extant service provision structures, resulting in mixed backing for and fewer opportunities to utilize SafeCare.

Discussion: The analysis offers key insights into multilevel factors affecting EBI implementation specifically within the context of a large clinical trial. We conclude by offering tools and strategies for researchers and child welfare professionals to ameliorate the challenges associated with participating in clinical trials while also endeavoring to simultaneously embed new EBIs in complex service systems.