Multi-level factors related to the successful implementation and sustainability of the National Diabetes Prevention Program Restricted; Files Only

Madrigal, Lillian (Fall 2022)

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To impact health outcomes at a population level, evidence-based interventions must be adopted, implemented, and scaled by a large number of organizations with sufficient population reach. Since 2012 the National Diabetes Prevention Program (National DPP) lifestyle change program has been scaled across the United States; however, further scaling and program reach are needed to make significant population change. In order to understand how the National DPP might better strategize and mobilize to increase its growth and impact, this dissertation explored the multi-level factors related to the successful implementation and sustainability of the National Diabetes Prevention Program through three aims.

This research focused on the facilitators and constraints both within and outside organizations that impact implementation outcomes. The first aim, used a qualitative construct rating analysis to identify key organization- and structural-level causal factors associated with the implementation within 30 National DPP organizations, particularly as it pertains to reach. The second aim sought to quantitatively test the direct and indirect relationships between the organization- and structural-level causal factors, organizational characteristics, and reach using structural equation modeling. Lastly, the third aim utilized latent profile analysis to identify patterns of sustainability capacity among delivery organizations and their associated organization characteristics. For aims two and three the analysis included 586 respondents from a online survey with National DPP implementers.

All three aims provided valuable information to help guide National DPP implementation efforts. Overall, basic program infrastructure and support, such a staff time, resources, and active leadership engagement were most salient and important to the National DPP implementers. In addition to this, this work also identified organizations working with particular populations (i.e. rural communities, non-white populations, etc.) may need additional or unique resources and assistance. These are very practical and seemly obvious factors that impact implementation, but the more evidence to support and emphasize that staff need sufficient resources, time, and supportive organizational environments to do their work is important.

This work contributes methodologically to the implementation science literature, both in study design and measurement. This dissertation will also directly impact training and technical assistance provided to delivery organizations to continue to support capacity building and its scalability. 

Table of Contents


Preface. 1

Study Aims. 2

Figure 1. Conceptual model: organizational factors related to implementation and program outcomes. 5

Chapter 1: Background & Significance. 6

Figure 2. A Multi-level Framework Predicting Implementation Outcomes (Chaudoir, Dugan, & Barr, 2003) 16

Table 1. Implementation Outcomes Definitions (Enola Proctor et al., 2011) 16

Table 2. CFIR Inner and Outer Setting Constructs and Sub-constructs. 20

Innovation. 30

References. 33

Chapter 2: Aim 1. 41

Abstract 41

Background. 43

Methods. 45

Table 1. Rating Criteria. 49

Results. 50

Table 2. Interviewee Organization Characteristics by Implementation Reach. 51

Figure 1. Construct Rating Matrix. 53

Discussion. 59

Conclusions. 64

References. 65

Supplemental Table. 67

Chapter 3: Aim 2. 71

Abstract 71

Background. 72

Figure 1. The Hypothesized Path Model 78

Methods. 78

Table 1. Adapted and Created CFIR Items. 80

Results. 83

Table 2. Organization/respondent characteristics (N=586) 84

Table 3. CFIR Inner and Outer Setting Likert-Scale Items and Mean Scores. 87

Table 4. CFIR Likert-Scale Construct Scores & Cronbach’s Alpha. 89

Figure 2. Final Structural Equation Model (n=445) 91

Table 5. Standardized Significant Coefficients (n=445) 91

Discussion. 91

Conclusions. 97

References. 97

Supplemental Tables. 100

Chapter 4: Aim 3. 112

Abstract 112

Background. 113

Methods. 116

Table 1. PSAT Domains and Definitions. 117

Results. 121

Table 2. PSAT Respondent & Organization Characteristics (N=440) 123

Table 3. PSAT Item Frequencies and Domain Average Scores (N=440) 125

Figure 1. Four Class Model of PSAT Domains. 128

Table 4. Four-Class Model Multivariable Multinomial Logistic Regression: Associations Between Organization Characteristics and Latent Profiles (n=259) 130

Table 5. Organizational Characteristics Associated with PSAT Scores. 132

Discussion. 133

Conclusion. 137

References. 138

Supplemental Tables & Figures. 141

Chapter 5. 161

Introduction & Summary of Key Findings. 161

Overall Themes. 163

Strengths, Implications, & Future Research. 165

Limitations. 170

Reflexivity. 172

Conclusion. 173

References. 174

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