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Servicenow-CIS-VR Certified Implementation Specialist - Vulnerability Response

The ServiceNow Certified Implementation Specialist - Vulnerability Response Exam
Specification defines the purpose, audience, testing options, exam content coverage,
test framework, and prerequisites to become Certified Implementation Specialist -
Vulnerability Response certified.

Exam Purpose

The Certified Implementation Specialist - Vulnerability Response exam certifies that a
successful candidate has the skills and essential knowledge to contribute to the
configuration, implementation, and maintenance of a ServiceNow Vulnerability
Response Implementation.

Exam content is divided into Learning Domains that correspond to key topics and
activities typically encountered during ServiceNow implementations. In each Learning
Domain, specific learning objectives have been identified and are tested in the exam.

The following table shows the learning domains, weightings, and sub-skills measured by
this exam and the percentage of questions represented in each domain. The listed subskills should NOT be considered an all-inclusive list of exam content.

1 Vulnerability Response Applications and Modules

• About ServiceNow Security Operations

• Introducing Vulnerability Response

• Vulnerability Response with the ServiceNow



2 Getting Data Into Vulnerability Response

• Definition of Vulnerabilities and Vulnerable Items

• Integrating with Vulnerability Scanners and Other

Data Sources

• Scanner Integration and CMDB Reconciliation


3 Tools to Manage Vulnerability Response

• Group Vulnerabilities for Easier Management

• Tasking for Vulnerability Remediation

• Exploit Enrichment


4 Automating Vulnerability Response

• Handling Vulnerability Exceptions

• Using Workflows for Process Automation


5 Vulnerability Response Data Visualization

• Data Visualization Overview: Dashboards and

• Performance Analytics


Total 100%

Exam Structure

The exam consists of (60) questions. For each question on the examination, there are
multiple possible responses. The person taking the exam reviews the response options
and selects the most correct answer to the question.

Multiple Choice (single answer)

For each multiple-choice question on the exam, there are four possible responses. The
candidate taking the exam reviews the response options and selects the one response
most accurately answers the question.

Multiple Select (select all that apply)

For each multiple-select question on the exam, there are at least four possible
responses. The question will state how many responses should be selected. The
candidate taking the exam reviews the response options and selects ALL responses that
accurately answer the question. Multiple-select questions have two or more correct

Exam Results

After completing and submitting the exam, a pass or fail result is immediately
calculated and displayed to the candidate. More detailed results are not provided to
the candidate.

Exam Retakes

If a candidate fails to pass an exam, they may register to take the exam again up to
three more times for a cost of $150.

Certified Implementation Specialist - Vulnerability Response
ServiceNow Implementation Study Guide

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CAS-PA ServiceNow Certified Application Specialist - Performance Analytics
CIS-FSM ServiceNow Certified Implementation Specialist - Field Service Management
CIS-VRM ServiceNow Vendor Risk Management
CIS-CPG ServiceNow Certified Implementation Specialist - Cloud Provisioning and Governance (CIS-CPG)

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Certified Implementation Specialist - Vulnerability
Question: 52
A list of software weaknesses is known as:
A. National Vulnerability Database (NVD)
B. Common Vulnerability and Exposure (CVE)
C. National Institute of Science and Technology (NIST)
D. Common Weaknesses Enumeration (CWE)
Answer: D
Question: 53
Vulnerability Response can be best categorized as a ____________, focused on identifying and remediating vulnerabilities as early
as possible.
A. A proactive process
B. An iterative process
C. A tentative process
D. A reactive process
Answer: A
Question: 54
In regard to the Security Operations Process, which of the following statements defines the "Identify" phase?
A. What processes and assets need protection?
B. What techniques can identify incidents?
C. What safeguards are available?
D. What techniques can restore capabilities?
E. What techniques can contain impacts of incidents?
Answer: C
Question: 55
Which module is used to adjust the frequency in which CVEs are updated?
A. NVD Auto-update
B. Update
C. CVE Auto-update
D. On-demand update
Answer: B
Question: 56
Changes made within a named Update Set in a different application scope:
A. Will be captured
B. Will throw errors
C. Will not be captured
D. Will be partially captured
Answer: A
Question: 57
ServiceNow Vulnerability Response tables typically start with which prefix?
A. snvr_
B. snvuln_
C. vul_
D. sn_vul_
Answer: D
Question: 58
SLAs are used to ensure VUL are processed in a timely matter. Which field is used to determine the expected timeframe for
remediating a VIT?
A. Updated
B. Remediation status
C. Remediation target
D. Closed
Answer: C
Question: 59
What is the minimum role required to create and change Service Level Agreements for Vulnerability Response groups?
A. sla_manager
B. admin
C. sn_vul.vulnerability_write
D. sn_vul.admin
Answer: D
Question: 60
Select the three components of a Filter Condition: (Choose three.)
A. Field
B. Sum
C. Operator
D. Value
Answer: ACD
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Fri, 15 Jan 2021 08:30:00 -0600 text/html
A Study Guide to Humanae Vitae

Written by the Priests and Pastoral Associates of Priests for Life


This study guide is based on the Vatican Translation of Humanae Vitae


Table of Contents:



Introduction to the Study Guide

Summary of the Introduction to the Encyclical and Section I: New Aspects of the Problem and Competency of the Magisterium

A Summary of Section II. Doctrinal Principles

Summary of Section III. Pastoral Directives 

Essay: Finding Our Way Back Home

Essay: Life, Purity and Humanae Vitae

Essay: The Transmission of Life -- On Whose Terms?

The Contraception of Grief: A Personal Testimony

Glossary of Terms




A Study Guide to Humanae Vitae

Fr. Frank Pavone, National Director, Priests for Life


Forty years is not a long time in Church history. Indeed, we are still living in the moment of Humanae Vitae (issued on July 25, 1968), and of the challenge it presents to the world.

Humanae Vitae does not identify the key problem of our day in the realm of sex or birth or "the pill," but rather in the myth that we can be God. Pope Paul writes at the beginning of the document, "But the most remarkable development of all is to be seen in man's stupendous progress in the domination and rational organization of the forces of nature to the point that he is endeavoring to extend this control over every aspect of his own life -- over his body, over his mind and emotions, over his social life, and even over the laws that regulate the transmission of life” (n.2).


The Pope here is painting a wider vision of the problem. We think everything belongs to us, but the reality is that we belong to God. "Humanae Vitae" means "Of human life." Human life came from God, belongs to God, and goes back to God. "You are not your own," St. Paul declares. "You have been bought, and at a price" (1 Cor. 6:19-20). Sex and having children are aspects of a whole cluster of realities that make up our lives and activities. We suffer from the illusion that all of these activities belong to us. “This is my life, my body, my choice.


The problem we face is not that our society is obsessed with sex. Rather, it is afraid of it-- afraid of the total reality and power of what it represents, where it comes from, and where it leads. Sex properly understood requires that we acknowledge God who made it. More than that, sex can never be separated from its purpose: to insert us into this immense, powerful movement of life and love that started when God said "Let there be light" (Genesis 1:3) and culminates when the Spirit and the Bride say "Come, Lord Jesus!" (Revelation 22:17).


Sexual activity means so much that it is wrong to diminish its message or deny its full reality: it belongs in the context of committed love (sealed by marriage) and openness to life precisely because this is the only context great enough to hold its message and reflect the greater reality to which the gift of sexuality points us and to which it commits us.


This is a reality that is bigger than all of us. It is the self-giving which starts in the Trinity, and is revealed in a startling way on the Cross, and then challenges each of us in our daily interaction with others, with God, and with our own eternal destiny. It is so real and so big that it is scary. That's why so many today are afraid of the full reality and meaning of sex. That's why Pope Paul VI wrote Humanae Vitae.


That is also why our Priests for Life pastoral team wrote this Study Guide. We have also established a special website,, to promote the teachings of this document. It is our daily prayer that this effort will lead many believers to understand, embrace, and proclaim the beautiful truth of human life. 




James J. Pinto, Jr., M.E.V.
Editor: A Study Guide to Humanae Vitae 


This Study Guide will be most effective if one first thoroughly familiarizes himself with its content and layout. Review the table of contents and the location of each section listed. The Study Guide is to be used by an individual or group as a side by side companion with the text  of Humanae Vitae included in this booklet. The three Essays offer unique insight with questions for further discussion. The Contraception of Grief: A Personal Testimony presents a riveting and practical witness to why Humanae Vitae is the wholesome truth.


The Glossary assists the reader in clarifying some key terms contained in the Encyclical. Glossary terms are listed by the number/paragraph in which they first appear. The terms will be marked with an *asterisk in the Humanae Vitae text as a note to the reader that the term is contained in the Glossary. 


After reading Fr. Pavone’s Foreword one should read the Summary of the Introduction and Section I, followed by the reading of the Introduction and Section I. of Humanae Vitae itself. After completing the Introduction and Section I. of Humanae Vitae; the reader answers the series of questions below the Summary of the Introduction and Section I.  The sequence followed for the Introduction and Section I is repeated for each following section: Reading the Study Guide Section Summary, reading of the corresponding Encyclical section itself and returning to the Study Guide questions for that particular section. The questions are meant to refer the reader back to particular paragraphs/numbers (n.or n.n.) of that section where he/she will find the answers. One may work on the answers to these questions while reading the paragraph/number, or, wait until he/she has read the entire section and then complete the answers. Continual returning to the text of the encyclical helps emphasize that the document itself is the primary source of instruction and the basis for individual and group applications. 


The three Essays have several questions at their conclusion to help foster reflection and discussion. A personal witness to the truth and wisdom of Humanae Vitae is presented in The Contraception of Grief: A Personal Testimony. 


This Study Guide is meant to be a “springboard” to delve more deeply into Humanae Vitae and its themes, in order to stimulate reflection, and a lifestyle of holiness. 


For those considering the possibility of facilitating a study group, this study guide lends itself to a discussion study group method of learning. While a leader/facilitator encourages the group and keeps it “on track”, it is the individual sharing and group dynamic that contribute most to the learning process. The facilitator is not a lecturer, neither is he there to give all the answers. The facilitator seeks to shepherd the group learning process and does everything possible to solicit their contributions. Members interact and learn from everyone, including the facilitator. A Facilitator’s Guide is available through Priests for Life at The Facilitator’s Guide seeks to assist you in leading a group and lays out suggested study sessions.


It is our hope, that on the fortieth anniversary of Humanae Vitae, this study guide will assist in promoting the Church’s clear and authoritative word on transmitting human life. May all who hear this true, prophetic and lovely word be assured that: the Church has always issued appropriate documents on the nature of marriage, the correct use of conjugal rights, and the duties of spouses. These documents have been more copious in recent times. (n.4)


Mon, 25 Dec 2023 10:00:00 -0600 en text/html
An Implementation Study on Fault Tolerant LEON-3 Processor System Z. Stamenković, C. Wolf, G. Schoof and J. Gaisler*
IHP GmbH, Frankfurt (Oder), Germany
*Gaisler Research, Göteborg, Sweden


The paper presents a case study on implementation of the fault tolerant LEON-3 processor system on a chip for space applications. The single-event upset (SEU) tolerance is provided by design. The technique applied detects and corrects up to 4 errors in the register file and caches. The implementation details and system-on-chip features are summarized.


The requirement to survive the rough trip into space is necessitating using radiation-tolerant electronics. Among radiation-tolerant electronics, radiation-tolerant (or fault-tolerant) processors play the key role. The heart of a fault-tolerant processor system must be a high-performance, high-speed, modular, low-power RISC microprocessor to meet the ever growing application demands of today’s and tomorrow’s space missions.

We present the fault-tolerant LEON-3 processor system that has been designed for operation in the harsh space environment, and includes functionality to detect and correct single-event upset (SEU) errors in all on-chip RAM memories. The fault-tolerant LEON-3 processor supports most of the functionality in the standard LEON-3 processor [1], and adds the following features:

  • Register file SEU error-correction of up to 4 errors per 32-bit word;
  • Cache memory error-correction of up to 4 errors per tag or 32-bit word;
  • Autonomous and software transparent error handling;
  • No timing impact due to error detection or correction.


The system includes a LEON-3 processor core, caches, a combined PROM/SRAM memory controller, an AMBA bus (AHB and APB) including an AHB controller and an AHB/APB bridge, and a standard set of peripheral cores including timers, UARTs, I/O port, interrupt controller and debug interfaces [1].

2.1 Processor Core

LEON-3 is a 32-bit processor core conforming to the IEEE-1754 (SPARC V8) architecture. It is designed for embedded applications, combining high performance with low complexity and low power consumption. The processor core has the following main features: 7-stage pipeline with Harvard architecture, separate instruction and data caches, hardware multiplier and divider, on-chip debug support and multi-processor extensions.

2.2 Caches

LEON-3 has a highly configurable cache system, consisting of a separate instruction and data cache. Both caches can be configured with 1 - 4 sets, 1 - 256 kbytes/set, 16 or 32 bytes per line. Sub-blocking is implemented with one valid bit per 32-bit word. The instruction cache uses streaming during line-refill to minimize refill latency. The data cache uses write-through policy and implements a double-word write-buffer. The data cache can also perform bus-snooping on the AHB bus. Both tag and data arrays are protected with four parity bits, allowing detecting up to four simultaneous errors per cache (tag or data) array word. Upon a detected error, the corresponding cache line is flushed and the instruction is restarted. For diagnostic purposes, error counters are provided to monitor detected and corrected errors in both tag and data arrays of the caches.

2.3 AMBA Bus

Two on-chip buses are provided: AMBA AHB and AMBA APB. The APB is used to access peripherals and on-chip registers, while the AHB is used for high-speed data transfers. The full AHB/APB standard is implemented [2].

AHB is designed for high-performance, high-clock-frequency system modules. It acts as a high-performance system backbone bus. This bus supports the efficient connection of processors, on-chip memories and off-chip external memory interfaces with low-power peripheral functions. LEON-3 uses the AMBA-2.0 AHB to connect the processor cache controllers to the memory controller and other high-speed units. In our configuration, two masters are attached onto the bus: the processor and the UART of debug communication link, and four slaves are provided: memory controller, debug support unit, JTAG, and AHB/APB bridge.

AHB/APB bridge acts as the only master on the APB. All communication between masters on the AHB and slaves on the APB pass through this bridge. The APB is optimized for minimal power consumption and reduced interface complexity to support peripheral functions. It is configured to connect five slaves: interrupt controller, timer, two UARTs, and parallel I/O port.

2.4 Interrupt Interface

LEON-3 supports the SPARC V8 interrupt model with a total of 15 asynchronous interrupts. The interrupt interface provides functionality to both generate and acknowledge interrupts. Interrupts from AHB and APB units are routed through the bus, combined together, and propagated back to all units.

2.5 Fault Tolerant Memory Controller

The fault tolerant 32-bit PROM/SRAM controller uses a common 32-bit memory bus to interface PROM, SRAM and I/O devices. In addition, it also provides an Error Detection And Correction (EDAC) unit, correcting one and detecting two errors. Configuration of the memory controller functions is performed through the APB bus interface.

2.6 Timer Unit

The modular timer unit implements one prescaler and one to seven decrementing timers. Number of timers is configurable through a VHDL-generic. The timer unit acts a slave on APB bus. The unit is capable of asserting interrupt on when timer(s) underflow. Interrupt is configurable to be common for the whole unit or separate for each timer.

2.7 I/O Port

I/O unit implements a scalable I/O port with interrupt support. The port width can be set to 2 - 32 bits through the nbits generic. Each bit in the port can be individually set to input or output, and can optionally generate an interrupt. For interrupt generation, the input can be filtered for polarity and level/edge detection.

2.8 UARTs

AHBUART consists of a UART connected to the AHB bus as a master. A simple communication protocol is supported to transmit access parameters and data. Through the communication link, a read or write transfer can be generated to any address on the AHB bus.

APBUART is provided for serial communications. The UART supports data frames with 8 data bits, one optional parity bit and one stop bit. To generate the bit-rate, each UART has a programmable 12-bit clock divider. Hardware flow-control is supported through the RTSN/CTSN hand-shake signals. Two configurable FIFOs are used for the data transfers between the bus and UART.

2.9 Debug Support Unit

The LEON-3 pipeline includes functionality to allow non-intrusive debugging on target hardware. To aid software debugging, up to four watch-point registers can be enabled. Each register can cause a breakpoint trap on an arbitrary instruction or data address range. When the debug support unit is attached, the watch-points can be used to enter debug mode. Through a debug support interface, full access to all processor registers and caches is provided. The debug interfaces also allows single stepping, instruction tracing and hardware breakpoint/watch-point control. An internal trace buffer can monitor and store executed instructions, which can later be read out over the debug interface.

2.10 JTAG Debug Link

The JTAG debug link provides access to on-chip AHB bus through JTAG. The JTAG link implements a simple protocol which translates JTAG instructions to AHB transfers. Through this link, a read or write transfer can be generated to any address on the AHB bus.

2.11 Power-down Mode

The LEON-3 processor core implements a power-down mode, which halts the pipeline and caches until the next interrupt. This is an efficient way to minimize power-consumption when the application is idle, and does not require tool-specific support in form of clock gating.


The LEON-3 processor system has been configured and implemented to support the single-event upset (SEU) tolerance of instruction and data caches. Each of the caches consists of a tag array and a data array. The tag array is implemented as an embedded SRAM block of 512 bytes. The data array is composed of two embedded SRAM blocks (one of 2 kbytes and another of 512 bytes). The register file has been implemented in flip-flops and protected against SEU errors. The triple-module-redundancy (TMR) has been provided on all flip-flops. A block diagram of the configuration is shown in Figure 1. The cache organization is presented in Table 1.

Figure 1: Implemented configuration of LEON-3

For system implementation and verification, we have used the original simulation and synthesis scripts [3] having provided necessary modifications. First, modifications have been done to incorporate custom SRAM Verilog simulation models into the original VHDL processor model.

Table 1: Cache organization

Cache Array Size (KB) No. of Words Data Width Address Width
I/D Data 2.5 512 36 of 40 9
I/D Tag 0.5 128 29 of 32 7

3.1 Synthesis

The system is fully synthesizable with most synthesis tools. After the configured processor system including SRAM models had been verified, we have modified the synthesis scripts to map the design into the target library. The design with directly instantiated SRAM blocks and pads has been synthesized for a target frequency of 125 MHz using Synopsys Design Compiler [4]. An SDF (Standard Delay Format) file of the synthesized gate-level netlist has been generated too.

3.2 Verification

A generic testbench is provided for generation of a few testbench configurations: FUNC testbench performing a quick check of most on-chip functions, MEM testbench testing all on-chip memory, and FULL testbench combining memory and functional tests, suitable to generate test vectors for manufacturing testing [3]. Numerous simulations using these testbenches have been carried out after synthesis to prove the correct functionality of the design gate-level netlist. All the simulations without and with the corresponding SDF file have been done using ModelSim simulator [5]. Same simulations are used for verification of the netlist of the generated layout.

3.3 Layout

After functionality of the synthesized netlist had been verified, we have created a floorplan using Cadence First Encounter [6]. In floorplanning phase, the memory blocks have been placed as hard macros. Design layout has been generated using a standard sequence of the back-end process steps: power planning, placement, clock tree generation, routing and verification of geometry. The processor system has been fabricated in the IHP’s 0.25µm CMOS technology [7]. The chip photo is shown in Figure 2. Geometrical and electrical features of the chip are summarized in Table 2. The data shows the high performance and low energy consumption of the implemented system-on-chip.

3.4 Testability

The design is highly testable as in addition to functional testing of the complete system-on-chip, a chain of scanable flip-flops (a scan-chain) is implemented. For the inserted scan-chain (made of more than 15000 scanable flip-flops), we have generated more than 1000 manufacturing test vectors by Synopsys TetraMAX Automatic Test Pattern Generator [8] in form of a WGL file. A Verilog DPV testbench has been prepared for serial simulation of all scan data too. All the tests (functional tests and scan test) are executed on the Agilent's chip tester 93000.

Figure 2: Chip photo

Table 2: System-on-chip features

Area (mm2) 22
Signal Ports 105
Power Ports 20
Scan Ports 1 (3)
Transistors (x106) 0.83
Cache Memory (kbytes) 6
Scanable Flip-Flops (x103) 15
Power/Frequency (mW/MHz) 6.2
Maximum Frequency (MHz) 160

3.5 Radiation test

To test the SEU tolerance, the LEON-3 processor has been subjected to heavy-ion-error injection using Californium (Cf-252). The tests have been carried out for 3 hours, with a flux of 25 particles/s/cm2 at the device surface. The on-chip monitoring logic reported a total of 281 effective SEU errors, of which 99% were corrected. The cross-section for a memory RAM bit was measured to 7.2E-8 cm2.


This paper presents an experience in implementation of the fault tolerant LEON-3 processor system configured to operate in space conditions. The implemented processor system has been verified and tested. We have demonstrated the performance and features of this processor system (fabricated in the IHP’s 0.25m CMOS technology) that meet requirements imposed by target application.


1. GRLIB IP Core User’s Manual, Gaisler Research
2. AMBA On-Chip Bus Standard, ARM Inc.
3. GRLIB IP Library User’s Manual, Gaisler Research
4. Design Compiler, Synopsys Inc.
5. ModelSim, Model Technology
6. First Encounter, Cadence Design Systems
7. SiGe:C BiCMOS technologies, IHP GmbH
8. TetraMAX ATPG, Synopsys Inc.

Wed, 06 Dec 2023 10:00:00 -0600 en text/html
Bringing Equity to Implementation

Bringing Equity to Implementation

Implementation science—the study of the uptake, scale, and sustainability of social programs—has failed to advance strategies to address equity. This collection of articles reviews case studies and articulates lessons for incorporating the knowledge and leadership of marginalized communities into the policies and practices intended to serve them. Sponsored by the Anne E. Casey Foundation

View the digital edition and download the PDF.

Thu, 20 May 2021 04:36:00 -0500 en-us text/html
Study Abroad Study Abroad

Skip to main contentSkip to main navigationSkip to footer content

ESF Education Abroad is devoted to making transformational international experiences accessible to all ESF students regardless of major, cost, identity, or other defining factors. We do this by working with students on an individual basis to find the opportunities that best fit their personal needs and goals.

ESF students have hundreds of education abroad programs to choose from! Programs vary in length from one week up to a full academic year and are located all over the world, so there is something for everyone! Start to browse programs below, and please reach out to with any questions or to start planning your experience abroad.


Program Details
ESF Short-Term Programs Travel abroad with an ESF faculty member and your classmates! Most short-term courses are between one to three weeks in length and take place over spring or summer break.
ESF Exchange Programs Spend a semester or summer abroad with one of ESF's university partners.
ESF Partner Study Abroad Study abroad for a winter, summer, or semester with one of ESF's recommended study abroad providers, any other SUNY institution or through another study abroad program provider. Many of these programs are immersive or field-based opportunities. Short-term, summer, and semester programs are all available!


Quick Tips

Before researching programs, think about your goals for education abroad. What type of experience are you hoping to have and what are you most interested in learning? What type of opportunities do you have limited access to in Syracuse and how might you gain those abroad? Use these questions to help guide you to better understand what it is you want out of your international experience and how you might be able to find a program that fits those criteria.

In addition to thinking about what is important to you, take some time to recognize what is not important to you. When choosing a education abroad program, it can be easier to find a "perfect" match if you understand what you are willing to compromise. Are financials the most the important piece to you? Specific classes for your major? Perhaps a research topic in a specific field? Rank the things that are most important to you so we can help you find that "perfect" opportunity.

You never know where you might find recommendations, advice or input. Ask your classmates, professors, advisors, parents, guardians, coaches, etc. You never know what you might discover. Don't forget to visit OIE as well – we serve as the repository for all of the different opportunities in front of you and can help guide you when you're not sure where to even start.

Fri, 14 Aug 2020 12:08:00 -0500 en text/html
Selecting Your Program

Our programs vary in length from a week to a full academic year.  We offer short-term programs that take place during the summer, spring break, or winter break, as well as long-term programs that cover one or two semesters. 

If you are looking for a semester program, consider whether you would prefer to go abroad in the spring or fall.  Due to differences in academic calendars around the world, some programs work best for Purdue students in one semester or the other, so the search allows you to specify.  If you are open to spring and fall programs, selecting the “Semester” option will bring up results for both.

For adventurous students, we also offer programs that cover two semesters!  Many returning students say they wish they had studied abroad longer, and the cultural immersion and cost effectiveness of a year-long program can be hard to beat. 

Students interested in summer opportunities often ask if they can search for Maymester programs.  We don’t categorize these separately from other summer programs, but it’s possible to search for programs beginning in May.  See “Program Start Month” below.

Wed, 03 Jun 2020 05:36:00 -0500 en-US text/html
A Qualitative Study of Factors Influencing Implementation of Tobacco Control in Pediatric Practices

1. Introduction

National Health and Nutrition Examination Survey (NHANES) data shows that 35.4% of children aged 3–17 years in 2013-2016 were exposed to tobacco smoke in the US [Reference Brody, Lu and Tsai1], despite well-documented risks from tobacco smoke exposure to children’s health [2, Reference Hill, Hawkins, Catalano, Abbott and Guo3]. Pediatric clinicians are uniquely positioned to address family tobacco use and reduce children’s exposure to tobacco smoke by helping families quit smoking [Reference Rosen, Ben, Winickoff, Hovell, Rosen and Noach4, Reference Winickoff, Berkowitz and Brooks5]. While clinical practice guidelines recommend that clinicians and staff in child healthcare settings, such as pediatric offices, screen families for tobacco use and provide guidance to reduce tobacco use and exposure [6Reference Farber, Walley, Groner and Nelson8], few pediatric practices routinely ask about tobacco use and offer evidence-based cessation assistance [Reference Winickoff, Nabi-Burza and Chang9, Reference Nabi-Burza, Drehmer and Hipple Walters10].

1.1. Clinical Effort against Secondhand Smoke Exposure (CEASE)

Research has shown that many child healthcare clinicians and staff lack the skills and confidence needed to address family tobacco use and exposure, revealing gaps in knowledge and in practice [Reference Winickoff, Park and Hipple11]. The clinical effort against secondhand smoke exposure (CEASE) intervention was developed to address such gaps [Reference Winickoff, Park and Hipple11]. The development of CEASE was and continues to be informed by evidence-based tobacco control guidelines [7, Reference Fiore, Jaen and Baker12], smoking cessation strategies and tools [Reference Spencer, Swanson, Hueston and Edberg13, Reference Rigotti14], and insights from tobacco control specialists, public health professionals, and clinicians [Reference Winickoff, Hipple and Drehmer15Reference Conroy, Majchrzak and Silverman17].

Through CEASE, child healthcare clinicians and staff are trained to address family smoking and family tobacco smoke exposure. The CEASE capacity building efforts are centered around two training calls (a peer-to-peer training call for practice champions and a training call for the whole office) [Reference Walters, Ossip and Drehmer18], with opportunities for additional training through an online CME program in tobacco control [19] and the American Academy of Pediatrics’ Maintenance of Certification online course in tobacco control [Reference Walters, Ossip and Drehmer18, Reference Winickoff, Dempsey, Friebely, Hipple and Lazorick20].

In line with ask, assist, and refer [Reference Schroeder and Cooper21], the core components of CEASE consist of screening families for tobacco using an iPad-based previsit screener and assisting with cessation by providing evidence-based tobacco cessation treatment and referral to free cessation support services to those who smoke. The previsit screener, which is used exclusively for the intervention, is given to the adult family member accompanying the child at the visit. The adult family member, commonly a parent or legal guardian (hereafter referred to as parent), completes the previsit screener before the parent and child are seen by the clinician; this often happens during check-in at the front desk, in the exam room, or at another previsit moment. The previsit screener identifies families exposed to tobacco smoke with this question: “Does any member of your household use any form of tobacco?” If the parent indicates that no members of the household use tobacco, no further questions are asked. Parents who report having a household tobacco user are asked additional questions. These questions include information about their child’s name, relationship to the child, and the parent’s own tobacco use status. If the parent is a current smoker, the screener is programmed to ask them about their interest in nicotine replacement therapy (NRT) patch and gum prescriptions and referral to the free state quitline and SmokeFreeTXT program [Reference Nabi-Burza, Winickoff and Drehmer22]. After the parent who smokes completes all questions, a member of the front desk staff gives the parent preprinted NRT prescriptions. If the parent indicates on the screener that he or she would like to be referred to the quitline, the front desk staff are prompted to give the parent a tobacco quitline enrollment form. When available from the state’s tobacco quitline, the previsit screener includes information about when to expect a call from the quitline and/or how the phone number would likely appear on their caller ID.

CEASE has been shown to be effective at helping parents quit smoking [Reference Nabi-Burza, Drehmer and Hipple Walters10]. The economic evaluation of the CEASE intervention showed an incremental cost-effectiveness ratio of $1132 per quit [Reference Drouin, Sato and Drehmer23]. However, less is known about the factors that influence the implementation of CEASE in pediatric office settings. Understanding the factors that influence the implementation of CEASE is crucial for the scale-up, sustainability, and dissemination of evidence-based family tobacco cessation interventions in child healthcare settings.

2. Methods

As part of a hybrid effectiveness/implementation study of CEASE in five intervention pediatric practices in five states (OH, NC, TN, VA, and IN) ( identifier: NCT01882348) [Reference Nabi-Burza, Drehmer and Hipple Walters10], interviews were conducted with pediatric clinicians and staff gain insight into the factors that influenced the implementation of CEASE in study practices.

2.1. Ethical Approval and Consent

The study protocol was approved by the Institutional Review Boards at the American Academy of Pediatrics, Massachusetts General Hospital, and individual practice IRBs when required. In addition, all respondents were consented before data collection, and verbal permission was given to record the interview.

2.2. Design

Practices were recruited into the hybrid effectiveness/implementation study through the American Academy of Pediatrics. Practices were eligible if they had parent smoking prevalence >15%, average patient flow >50 families/day, >four full-time clinicians, and used an electronic health record (EHR). Eligible practices that expressed interest conducted three-day practice population surveys (PPS) to confirm parent smoking and patient flow rates.

As part of the study, intervention practices were asked to identify a pediatrician to serve as a practice champion, who would support the implementation of CEASE in their practice. Also, a member of the office staff, such as an office manager, was asked to serve as a coordinator for the CEASE study and the implementation of CEASE in their practices. The practice champion and the coordinator at each practice were asked to participate in interviews about implementation of CEASE in their practices.

Interviews were conducted two years after the start of CEASE implementation, which is defined as two years after clinicians and staff were trained in the intervention and after practices began using the iPad-based previsit screener to screen families for tobacco use and exposure. The semistructured interviews were conducted via telephone between November 2017 and January 2018 by a PhD-level researcher who was a part of the CEASE research team (BHW).

2.3. The Use of the Consolidated Framework for Implementation Research

The consolidated framework for implementation research (CFIR) is a comprehensive, theory-informed, and adaptable implementation research framework consisting of five domains that have been shown to shape the implementation of interventions; these domains are intervention characteristics, the outer setting, the inner setting, the characteristics of individuals, and the process of implementation [24, Reference Safaeinili, Brown-Johnson, Shaw, Mahoney and Winget25]. Each of these domains consists of a variety of subdomains, which help provide further details for each of the domains. In the CEASE study, the CFIR was used to develop the interview guide and to analyze data collected through interviews.

2.4. Interview Guide

Clinicians and staff were interviewed using questions from an interview guide, which consisted of tailored questions from the CFIR interview guide [Reference Kirk, Kelley, Yankey, Birken, Abadie and Damschroder26, Reference Damschroder and Hagedorn27] and questions specific to the CEASE intervention. The interview guide was reviewed by the study’s steering committee and further improved based on feedback from an external qualitative researcher who reviewed it for potential leading questions, relevance, and clarity.

2.5. Interview Process

The phone interviews lasted between 45 and 60 minutes. In the preinterview briefing, respondents were encouraged to be open and honest, there were no right or wrong answers, the focus of the interview was to learn about their experiences with implementing CEASE, and respondents had the right to stop the interview at any time or to skip questions. The respondents were assured that the data would be anonymized.

2.6. Data Analysis

The interview recordings were transcribed verbatim using an external service. The transcriptions were read closely and anonymized by BHW. She then shared the cleaned transcripts with ENB. Both coders (BHW and ENB) closely read all transcripts before coding.

Once the transcripts had been cleaned and read, BHW began inductively coding five transcripts. The codes that were uncovered during this initial coding process were used to develop the codebook. The codebook included key terms (codes), definitions of the codes, inclusion and exclusion criteria for each code, and an example quote that was representative of each code. After this initial development, the codebook was shared with the second coder (ENB), who coded a sample of the transcripts and added to the codebook. The revised codebook was then reviewed by both coders; both coders then met to discuss any questions about the codebook. After this meeting, the codebook was approved and finalized. The final codebook contained 33 codes. The final codebook was used as a guide for coding all transcripts.

The transcripts were coded independently by the two investigators. Coding was done in Word. Each code was documented onto its respective code page. The coder copied relevant quotes from the transcript into the relevant code page. If a quote met the inclusion criteria for two codes, the quote was copied into the relevant code pages for both codes. This was done for all transcripts. After all of the transcripts were coded, the coders had a series of five- to six-hour-long meetings in which they compared their code pages for each of the codes. During these meetings, the coders discussed any differences in coding and resolved them based on the contents of the quote, each code’s definition, each code’s inclusion criteria, and each code’s exclusion criteria. At the end of these meetings, all coded data had been reviewed and agreed upon by both coders, resulting in a final set of coded data.

The coded data was analyzed using a thematic approach [Reference Braun and Clarke28]. Themes and included categories were organized into a thematic framework. Major themes were mapped to the domains of the CFIR [24, Reference Damschroder, Aron, Keith, Kirsh, Alexander and Lowery29]. Table 1 presents the CFIR domains with definitions, relevant constructs with definitions, and major themes from the data mapped to the domains.

3. Results

The interviews were conducted with 11 respondents from the five intervention practices. Of these, four respondents were MDs, one was a receptionist, five were office managers, and one was a practice nurse. In one practice, the office manager was also a clinical provider (nurse) at the practice and was the most involved in the intervention implementation, so she was the only one interviewed at that practice.

3.1. Intervention Characteristics that Influence CEASE Implementation

The CFIR defines intervention characteristics as “key attributes of interventions that influence the success of implementation. The core components and characteristics of CEASE included screening for tobacco use using the iPad, referring parents to the free state smoking cessation telephone support service using a fax-to-quit form, and prescribing NRT to parents using pre-printed prescriptions.” These “key attributes” [24] of CEASE shaped, in part, how practices implemented the CEASE intervention. Interview data provided insight into practice implementation and the adaptability of CEASE, as well as the complexity of CEASE.

3.1.1. The Adaptability of the CEASE Intervention

The adaptability (the degree to which an intervention can be adapted, tailored, refined, or reinvented to meet local needs) of the CEASE intervention was a recurring theme in the interviews. During trainings and communication with the CEASE study team, practices were encouraged to tailor the adaptable periphery of CEASE [24], such as health education materials and the use of the iPad screener, to work within existing practice workflows and to meet the needs of the practice’s patients and their families.

Respondents reported adapting CEASE to work within their practice’s existing workflow and processes. The practice 2 office manager stated that “we looked at our processes and changed things, tweaked it a little bit… we were able to kind of overcome a lot of those things and get back to this being part of the workflow instead of this added thing.” Other practices reported changing the process of using the iPad to screen parents for tobacco use and exposure; the practice 1 pediatrician explained “instead of doing [the iPad] at all visits, we did it only at well-child visits.”

Adapting CEASE included tailoring the provided parental health education materials, as well as creating additional, practice-specific health education materials to help parents quit smoking. The practice 1 pediatrician noted that “we put the handouts together about how to use patches correctly, and we also put in the information for the quitline and we put information in [about] tobacco classes, free classes from (inaudible) hospital that were offered so that you get free nicotine patches. So we tried to, ourselves, do some education for our patients.”

3.1.2. The Complexity of the CEASE Intervention

During the interviews, many pediatricians and office staff shared that using iPads to routinely screen for parental tobacco use was a complex aspect of the CEASE intervention, as it could involve the use of a new tool (the iPad), a different or longer check-in process for families, additional tasks for staff, and/or resistance from parents. Some of the complexity of using the iPad screener was related to how families reacted to the intervention; the office manager at practice 4 mentioned that “I think the only issue we had was people taking it over and over again that weren’t interested in it.” In other cases, the complexity of the screener was related to the process of using it routinely in practice. The pediatrician at practice 4 noted that “handing out the iPad at the front desk, I think, was not an easy thing to implement.”

While using the iPads may have been complex for practices, some respondents noted their pride in being able to screen most of their families for tobacco use. The practice 3 office manager noted that “some days we were really busy, and we were trying to catch them with all the iPads, and it maybe slowed down a little bit. But at the end, we were happy that we could manage to do it with every family.”

3.2. The Role of Outer Setting in the Implementation of CEASE

The implementation of the CEASE intervention was shaped by factors outside of the pediatric practices. The factors included the needs of patients and their families, external policies governing the care provided by practices, and external incentives for clinicians and office staff.

3.2.1. The Needs and Resources of Patients and Their Families

Interview respondents noted that their communities and their patient populations were in need of an intervention to address tobacco use and children’s exposure of tobacco smoke. The CEASE intervention was seen as a potential way of addressing the needs of families with regard to tobacco use and exposure. The practice 2 office manager explained that “I think (it was needed) within our population just because it’s largely tobacco using. I think it was definitely needed in our area for sure.” Further, a pediatrician in practice 3 noted that “we have 30, 20-25 percent of patients per day (with) parents that smoke so definitely we get secondhand and thirdhand smoke, (which) we can decrease. And it’s going to definitely going to help the children, their sickness, their getting repeatedly sick, those asthma patients.” The perceived need for such an intervention may have influenced how, to what extent, and with which families practices used the CEASE intervention.

Many of the practices in the study served high need, low-income families with high rates of tobacco use; during the interviews, practice staff and clinicians reported that their practices had high number of patients insured through Medicaid, which is commonly associated with higher levels of tobacco use [Reference Jamal, Phillips and Gentzke30]. The practice 5 office manager stated that “at least 50 percent of our patients are Medicaid patients.” While many of the children seen at the practices were insured through Medicaid, interview respondents noted that many parents lacked health insurance for themselves. The practice 4 pediatrician noted that “it was eye-opening to me to realize how many of our parents do not have insurance.” In addition to many parents having no insurance, respondents also noted that parents did not have the financial resources to pay for cessation medication out-of-pocket. The practice 4 office manager explained that “there were people that wanted to quit; they just really couldn’t afford the patches or the gum, and they didn’t have any insurance.”

3.2.2. External Policies and Incentives

Interview respondents noted that it could be difficult for parents to access smoking cessation medication due to financial constraints. However, at various time during the implementation of CEASE, some of the state quitlines offered free nicotine replacement therapy to those enrolled in quitline services. This free NRT served as an external incentive for the practices to enroll parents in the quitline; the practice 2 office manager noted that “sometimes they (quitline) would offer two free weeks of NRT for anyone no matter what their insurance status…. So that was a great support.” Practices were motivated and indirectly incentivized to enroll parents in the quitline by this external policy of free NRT.

3.3. The Role of the Inner Setting in the Implementation of CEASE

Respondents described how the structure of the practices, the context and culture of the practices, the organizational incentives for implementing CEASE, and the other programs and care provided by the practices influenced the implementation of CEASE in their practices.

3.3.1. Implementation Climate: Organizational Incentives

Organizational incentives to implement an intervention include tangible and intangible incentives, such as increased opportunities for payment and potential for advancement or professional development [24].

During the interviews, a few respondents noted that payment (or the hope of payment) from insurance companies helped their practice implement CEASE. The practice 4 office manager explained that “it’s not a large amount by any means, the ones [insurance providers] that do pay on it. But it was just that extra incentive to get $10 to $20 a visit extra because you spent some time counseling with the patient… So that was a pretty big incentive, and like I said, when we figured that out that was when the doctors, kind of, took ownership of it because of the financial incentive as well.” The additional funds served to support implementation and motivate some pediatricians to spend more time talking about smoking cessation with parents. However, many practices were not able to successfully bill insurance companies for the services that they provided, even when payment for those services was legally obligated [Reference Mann31].

Not all incentives to implement CEASE were directly financial. As one respondent noted, the Maintenance of Certification (MOC) course offered through CEASE was an incentive in and of itself. While the MOC course does have a monetary value, the added value for participants was seen to be in the overlap between the CEASE training and the MOC course; as part of CEASE, pediatricians were already learning and practicing much of the content of the MOC. The practice 4 pediatrician stated that “it was for MOC credit and all of us are scrambling for that MOC 4 credit because MOC 4 is the hardest to get… So that was a good incentive to get everybody.” The course served as both a resource and an incentive to implement CEASE. As MOC credits are required to maintain certification, this aspect of CEASE can be seen as an indirect “organizational incentive” [Reference Damschroder, Aron, Keith, Kirsh, Alexander and Lowery29].

3.3.2. Implementation Climate: Relative Priority

Many respondents described facing conflicting priorities and demands on their time, which impacted the implementation of CEASE. The practice 3 pediatrician stated “we’re doing a study on asthma. We’re doing a study on digestion. We’re doing a study on breastfeeding. And when you do so many things, time was a constant (problem),” while the practice 1 pediatrician noted that “we’ve got to do all the regulatory stuff that is being asked of us in well-visits and sick-visits. So, adding this extra CEASE component really was kind of a juggling act for us, if you can imagine that.” The office manager at practice 4 noted that “Probably the biggest obstacle for us was the amount of presumed work it was to get the iPad component embedded in what we were doing because when patients come to the front desk to check in they’re already confronted with a variety of things they have to fill in each time, whether it’s the developmental screening, or changes in their insurance information, or whatever, or verification of those things.” Many respondents noted that sometimes they had other priority tasks to complete which were seen as a barrier to the implementation of CEASE.

3.3.3. Culture

The culture of an organization—“the norms, values, and basic assumptions” [24]—influences how an intervention is implemented. The respondents noted that the alignment of the goals of the intervention with the organizational culture affected the intervention implementation in a positive way. This was reflected in practice 1 office manager’s quote, “I think we’re very involved in the community and making sure that our population and community is healthy …. [I] feel like ethically, that’s what we have to do”; the practice 1 office manager went on to say that “we were able to make a positive impact on not only the health of our parents, but also our children that we see. So I feel like culturally, it [CEASE] fit right in with what we do.” Interventions that align with the overarching culture of an organization tend to be more successfully implemented [Reference Damschroder, Aron, Keith, Kirsh, Alexander and Lowery29].

3.4. Characteristics of Individuals

During the interviews, pediatricians and office staff described how their personal beliefs and knowledge about parental tobacco use and the tobacco smoke exposure of children motivated them to implement CEASE. They also described the ways in which their knowledge and beliefs shaped the way that they worked with other staff members to implement CEASE in their practices.

3.4.1. Knowledge and Beliefs about Family-Centered Tobacco Control

Many respondents described their belief that addressing parental tobacco use and the tobacco smoke exposure of children was an important responsibility of child healthcare clinicians. The practice 1 pediatrician stated that “I feel very, very strongly that there are certain things that we should be doing as healthcare providers to keep certain general healthcare parameters high on the radar because if we don’t tell our patients that we’re concerned and think these things are important, they’re not going to see that as an important thing. So, if we don’t have smoking as something that we talk about, to try and educate and to let them know that we think that this is an important issue to address, just like obesity and healthy lifestyle -- if we’re not actively promoting those things, then I think we’re not fulfilling our mission.” The implementation of CEASE, then, helped the pediatrician and their practice to fulfil their sense of mission.

Respondents described how CEASE gave them the motivation, tools, and knowledge needed to address parental tobacco use. The practice 5 pediatrician stated that “I am proud that we’ve actually talked -- because it did get us to discuss more of secondhand smoke for kids, and thirdhand smoke, and what that meant. I am proud that we actually did talk to parents about that… So, I think that was good because it got awareness out there, so parents actually know that we were serious.” Through CEASE, clinicians were able to share their knowledge to increase awareness of second- and thirdhand smoke while also sharing their beliefs in the seriousness of parental smoking and the tobacco smoke exposure of children.

3.5. Process of Implementing CEASE

Through the interviews, pediatricians and office staff were asked to describe how the practice is prepared for implementing CEASE and the workflows and step-by-step actions conducted by different staff members used to implement CEASE in their practices and to share insight into how staff worked together to implement CEASE.

3.5.1. Preparing for and Engaging with CEASE

Respondents described how working together, such as brainstorming as a team, was a part of their practices’ implementation process. The practice 1 receptionist said that “we actually had a meeting -- a staff meeting with the nursing staff, clerical staff, and the providers, and I think we were just brainstorming ways of how to make this process run smoother.”

In addition to brainstorming and planning at the beginning of the CEASE project, pediatricians and office staff described how they adapted the workflow and different staff roles over time, engaging with one another to improve the process of implementing CEASE in their practices; the practice 4 office manager noted that “In the beginning, I think, the doctors thought it would be more of a nurse-and-reception thing and it -- it wasn’t going so well, so we switched up, and they took a lot more ownership in it, I guess, and that was when we saw more success.” Engaging with CEASE—“involving appropriate individuals in the implementation and use of the intervention”—was a process that evolved and adapted over time to meet the changing needs and realities of practices [24].

3.5.2. Practice Champions for CEASE

During the interviews, pediatricians and office staff noted that having a supporter of the intervention helped in motivating other staff. The practice 3 office manager said that “somebody who is motivated be behind you and tell you, ‘Just keep going. We’re not going to stop.’…. ‘How many do we want to do today? How many … people (are) coming to us today?’ So, to have that motivation is very good,” while the practice 1 office manager noted that “he was up there talking about why it’s important; I think it made people understand how, yes, this is something they need to do….. So I feel like those are things that helped encourage people to become more involved.”

4. Discussion

This qualitative study explores the factors that influenced the implementation of CEASE, an evidence-based family-centered tobacco control intervention, in five pediatric practices in the US. Interviews using questions from the consolidated framework for implementation research provided insight into the implementation of CEASE; the domains and subdomains of the CFIR provided a structure to understand the factors that may have influenced the implementation of the CEASE intervention in pediatric office settings. Through the interviews, pediatricians and staff indicated that the implementation of CEASE was shaped by

  1. (i) the adaptability and the complexity of the intervention (CFIR domain: intervention characteristics)

  2. (ii) the needs and resources of the patients and their families (CFIR domain: outer setting)

  3. (iii) incentives for implementing CEASE and practice’s culture (CFIR domain: inner setting)

  4. (iv) knowledge and beliefs about family-centered tobacco control (CFIR domain: characteristics of individuals)

  5. (v) engaging staff with CEASE and practice champions for CEASE (CFIR domain: process) [24, Reference Safaeinili, Brown-Johnson, Shaw, Mahoney and Winget25]

4.1. Perceived Complexity of (Implementing) CEASE

As described by the CFIR, interventions (and implementing these interventions) can be understood as complex when they have both core components and an adaptable periphery—elements of the intervention and of the implementation of the intervention that can be adapted by staff at the practice to meet the practice’s needs [Reference Damschroder, Aron, Keith, Kirsh, Alexander and Lowery29, Reference Stokes, Tumilty, Doolan-Noble and Gauld32]. Interventions are also considered complex when they have a number of interacting components and involve (potentially) difficult changes to behaviors and activities by those conducting the intervention [Reference Craig, Dieppe, Macintyre, Mitchie, Nazareth and Petticrew33]. In their guidance on how to evaluate complex interventions, G. Moore et al. noted that programs to help people quit smoking are often complex [Reference Moore, Audrey and Barker34]. Using these conceptualizations, the CEASE intervention and its implementation can be seen as complex. Data from the interviews revealed that having the ability and flexibility to adapt components of CEASE and its implementation was seen as an opportunity to adapt CEASE to the practice, using an iPad to routinely screen for tobacco use, and exposure was often viewed as difficult and disruptive. This complexity may influence how CEASE is scaled up to nonresearch practices, as well as to what extent practices can engage with and sustain CEASE over time.

4.2. Needs and Resources of Patients and Their Families

The implementation of CEASE was shaped by factors outside of the pediatric clinicians and office staff. The overall effect of factors in the outer setting is similar to what Pettigrew et al. [Reference Pettigrew, Ferlie and McKee35] called the “receptive context for organizational change,” which emphasizes identifying the external factors that that influence intervention implementation and the importance of interventions to adapt to these factors. Implementation can be positively influenced by the degree to which an intervention meets the perceived needs of patients and their families [Reference Feldstein and Glasgow36]. Studies have also shown that smokers with lower incomes are less likely to use evidence-based smoking cessation treatments like pharmacotherapy than smokers with higher incomes [Reference Fu, Sherman, Yano, Van Ryn, Lanto and Joseph37, Reference Burns and Fiore38]. Although Medicaid covers NRT patch and gum [Reference Mann31], many insurance companies do not cover it, and many parents do not have any insurance. While CEASE has been designed to use existing evidence-based counseling programs and covered medications to help parents quit smoking, this relies on the programs and medications being easily and feasibly available to parents. Without enforcement of required medication coverage at the insurance company level and availability of free tobacco quitline and texting programs, it may be difficult for parents to access the treatments prescribed by pediatricians as part of the CEASE intervention.

4.3. Incentives for Implementing CEASE and the Practice’s Culture

The inner setting of practices also played a key role in the implementation of CEASE. Financial incentives, such as receiving payments from insurance companies for the time spent in addressing the tobacco smoke exposure of children, was seen as an incentive by some respondents. Other nonfinancial incentives included the opportunity to earn MOC credits required to maintain certification and a CME-awarding course on tobacco control. These findings are consistent with the literature that suggests that incentives, including financial incentives and performance evaluations, positively influenced intervention implementation [Reference Helfrich, Weiner, McKinney and Minasian39].

4.4. Knowledge and Beliefs about Family-Centered Tobacco Control

The respondents’ knowledge of CEASE and beliefs about tobacco use influenced its implementation. These beliefs are important to understand at the individual and practice level to assess quality of implementation and prospects for sustainability [Reference Klein and Sorra40]. Adequate knowledge of the intervention affects the adoption of the intervention, and often, opinions based on personal beliefs and experiences are convincing and help to generate enthusiasm about the intervention [Reference Rogers41].

4.5. Engaging Staff with CEASE and Practice Champions for CEASE

The interview data showed that having individuals who are internally motivated to support implementation influenced how the intervention was implemented in their practices as they served as a driver of motivation. Engaging staff in a meaningful problem-solving manner is a critical element to transform patient care [Reference Lukas, Holmes and Cohen42]. Data also showed that engaging staff and reflecting on the reasons for doing the intervention was key to implementation. Dedicating time for reflecting or debriefing during and after implementation was one way to promote shared learning and motivation along the way [Reference Edmondson, Bohmer and Pisano43].

Table 2 presents the main challenges faced that were learned from this qualitative study and the implications and improvements for dissemination and sustainability of the intervention.

Table 2: Challenges and implications for sustainability and disseminability of the intervention.

4.6. Limitations

The small sample size may limit generalizability of results, though the themes identified were consistent across five practices and enhance the likelihood that the findings are not unique to a specific pediatric practice [Reference Lincoln and Guba44]. The results are limited to respondents who agreed to take part in interviews, which could have resulted in selection bias. Respondents other than those interviewed may have had different responses than those reported here and may not be representative of other pediatric clinics. However, we aimed to interview both clinical and administrative staff from each practice to get the overall picture of intervention implementation. Since the interviews were conducted with respondents from five pediatric practices in five states across the US, the diversity of the sample gives us greater confidence that the findings of this study may be applicable and potentially transferable to other US pediatric clinics [Reference Lincoln and Guba44].

5. Conclusion

This study examined the implementation of an evidence-based tobacco control intervention, CEASE in pediatric outpatient settings. We identified certain factors that may help improve implementation and sustainability of tobacco control interventions in the future. Findings from this paper emphasize the importance of intervention characteristics (more adaptable and less complex), inner setting (incentives for implementing CEASE and practice’s culture), outer setting (addressing the needs and resources of patients and their families), characteristics of individuals (knowledge and beliefs about the intervention), and the process of implementing an intervention (engaging all staff roles with CEASE and having practice champions for CEASE). By attending to these factors, future tobacco control interventions will have the best possible chance of sustainable integration into routine care delivery and enhanced likelihood of effective dissemination.

Mon, 01 Jan 2024 06:42:00 -0600 en text/html
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