Elucidating how external facilitation worked in a large-scale implementation of an evidence-based secure firearm storage program in pediatric primary care: A mechanistic analysis of the ASPIRE trial

Document Type

Conference Proceeding

Publication Date

6-20-2025

Publication Title

Implement Sci

Keywords

Health Care Sciences & Services

Abstract

Background: One way to increase the pace of implementation is to uncover the minimum necessary mechanisms activated by effective implementation strategies. The Adolescent and child Suicide Prevention in Routine clinical Encounters (ASPIRE) trial demonstrated that adding practice facilitation to an electronic health record (EHR) reminder and clinician training (“Nudge+”) increased reach of an evidence-based firearm storage program (S.A.F.E. Firearm) to youths (ages 5–17) in pediatric primary care by 27-percentage-points (N=47,307), relative to the reminder and training alone (“Nudge”). In the present analysis, we used mixed methods to examine the mechanisms through which facilitation increased program reach. Methods: ASPIRE was a hybrid type III effectiveness-implementation trial in which 30 practices were randomized to Nudge or Nudge+ to test which strategy was most effective for increasing reach of S.A.F.E. Firearm. Reach was defined as parent receipt of both components of S.A.F.E. Firearm (i.e., brief counseling and offer of cable lock) during a well-child visit. Quantitative mediation analyses tested whether the superiority of practice facilitation (Nudge+) was explained by increased practice adaptive reserve (i.e., clinic-level capacity to make and sustain change). Qualitative analyses of semi-structured interviews with 37 clinic leaders, change agents, and clinicians explored alternative mechanisms through which facilitation enhanced reach. Findings: Mediation analyses indicated facilitation’s superior effect on reach was not explained by improved practice adaptive reserve. Qualitative analyses indicated facilitation’s superiority may be explained by the increased logistical support, tailoring of supports to clinic context, reinforcement of clinician training, fostering of positive relationships within clinics, and increased constituent buy-in to the program, promoted by facilitators. Implications for D&I Research: Whereas previous research suggests facilitation works by increasing practice adaptive reserve, results from ASPIRE indicated other factors were most important for explaining how facilitation influenced reach relative to the EHR reminder and training alone. These differences may be due to the less complex practice being implemented (S.A.F.E. Firearm) in the ASPIRE trial relative to prior research, and the less intensive nature of facilitation (8.7 hours per clinic over 12 months). The elucidation of these factors as potential mechanisms of facilitation, and the identification of potential moderators of facilitation’s effects (e.g., intervention complexity), are important areas of future inquiry.

Volume

20

Issue

SUPPL1

First Page

1

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