New Directions in Implementation Science: Integrating Multiple Interventions

Working under a deadline can be a great source of motivation for many. When the re-invigorated Cancer Moonshot was announced in 2022, I found myself thinking about how we could collectively make enough progress to meet that audacious goal. Several leaders have outlined what it will take from the basic science and clinical research communities as well as public health professionals and policymakers (National Cancer Plan 2023; Shiels et al. 2023; Singer 2022). In addition to better understanding the biology and genetics of cancer and developing new treatments, it is critical that we work to ensure that what we already know works to prevent cancer, detect it early, treat it successfully, and support survivors is used in practice and accessible to everyone who needs it.

There is an important role for implementation science in this mission. Clichés like “work smarter, not harder” and “do more with less” came to mind as I pondered what would be needed to decrease cancer mortality by half by 2047 and increase quality of life for the increasing number of survivors nationwide.

Last year in the JNCI Cancer Spectrum, Dr. David Chambers and I outlined integration of multiple interventions as one potential tool to help get closer to the prevention and clinical care delivery goals of the Cancer Moonshot. Building from research considering integration of multiple cancer screening types and other efforts to leverage existing healthcare appointments to add cancer control interventions, we proposed two types of integrated interventions and discussed several examples:

• Blended intervention – When components from two or more evidence-based interventions focused on at least two behaviors or health topics that have been harmonized into a holistic intervention and are no longer distinguishable as separate…
• Bundled intervention – An approach to deliver multiple distinct behavior change and/or clinical evidence-based interventions, simultaneously or intentionally sequenced over time, to address multiple health or disease outcomes…

In the article, we also mused about how such integrated interventions could be best designed, outlining likely relevant considerations, and offered some potentially fruitful research directions that could ultimately help guide future implementation of integrated interventions in practice.

Around the same time in 2023, Proctor and colleagues published a scoping review in Implementation Science that looked at advances in implementation outcomes conceptualization and measurement. In their review of 400 articles, they reported that 7.3% included an element of innovation by studying multiple evidence-based practices (EBPs) in a single study. Very few of the articles that studied multiple EBPs seemed to be studying blended or bundled interventions as outlined above. None of them explicitly mentioned cancer prevention or control. They stated:

“Most included studies examined the implementation of a single evidence-based intervention or implementation object, failing to capture the reality of organizations and systems that typically work to introduce, implement, and sustain the simultaneous delivery of multiple interventions. Studying the implementation of multiple interventions carries logistic, resource, and design challenges but can make scientific leaps, particularly regarding external validity. Future research should examine how service system directors weigh acceptability, feasibility, and cost while selecting interventions and strategies and how they juggle simultaneous implementation efforts, stagger their timing, and sustain them in dynamic and unpredictable environments.”

In the cancer realm, investigators at the NCI-funded Implementation Science Center for Cancer Control Equity recently published an evaluation of a bundled intervention, which integrated colorectal cancer (CRC) screening and social drivers of health (SDOH) screening and referral/navigation. They found ~2x higher odds of CRC screening during the implementation period compared to the control period but no significant difference for SDOH screening. They concluded:

“With the significant staffing constraints that FQHCs [Federally-qualified health centers] face, being able to address two screening topics and maintain and even improve CRC screening uptake is highly relevant and important. This simple outreach strategy to improve a long-standing screening requirement, CRC screening, remained effective at increasing cancer screening even when bundled with a newer screening requirement [SDOH] among complex patient populations. This bundling strategy which improved cancer screening without negatively affecting SDOH screening may produce resource savings especially relevant in safety-net care systems.”

Clearly, the topic of integrating multiple interventions and research opportunities in this space are generating interest in the field. To provide a space for continued conversation, on May 22, 2024, at 3:00 p.m. ET, the Implementation Science Team at NCI will be hosting a webinar on this topic. The webinar will provide an overview of the Villalobos and Chambers article, and then invited guests Dr. Victoria Champion and Dr. Shannon Self-Brown will share examples of blended and bundled interventions from their research. We invite you to join us for this discussion with the panelists on lessons learned and research opportunities in this space. Register today!