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Oby: From the campus of Harvard Medical School, this is ThinkResearch, a podcast devoted to the stories behind clinical research. I'm Oby, your host. ThinkResearch is brought to you by Harvard Catalyst, Harvard University's Clinical and Translational Science Center, and by NCATS, the National Center for Advancing Translational Sciences.

The Implementation Science Journal defines implementation research as "the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice and, hence, to improve the quality and effectiveness of health services."

On today's episode, join us as we talk with Dr. Gina Kruse, clinician investigator at Massachusetts General Hospital and implementation lab director at the Implementation Science Center for Cancer Control Equity at Harvard TH Chan School of Public Health. Join us as we discover the real world applications of implementation research and its impact on underserved communities.

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Hi, Dr. Kruse. Welcome to the show.

Gina Kruse: Thanks so much for having me.

Oby: Of course. So you're currently a clinical investigator in the Division of General Internal Medicine at MGH. Could you walk us through your career path and maybe some of your upbringing that influenced some of your work?

Gina Kruse: So let's see, so I'm from rural Colorado. I grew up on a cattle ranch. We moved around a bit to a couple of different farms in a couple of different states but always out west and always with cattle around. And I went to college thinking I was going to be a large animal veterinarian. I worked my way through college and did work study in an immunology lab where I sort of had my first research experience.

And I found that I didn't love cleaning glassware, but I did really like the statistics and the study design and the hypothesis testing. So between work study and like an honors thesis, really got a taste for research. And also, somewhere along the way, some of my animal science advisors had suggested I consider human medicine as well as animal medicine because of the flexibility offered in the different variety of career paths.

And so I did. I did start to think about humans. And I guess the last little thing there that's kind of a funny little tidbit on the career path was my advisor was a geneticist in the Department of Animal Science. And their brother went to Baylor College of Medicine. And that must have stuck because that was where I went a few years later.

But before I got to medical school, I sort of had to figure out what I was getting into with this human medicine business because all of my experience had involved livestock before that. So I did some shadowing. And I actually did a master's degree in rural health services research so looking at access to care in places like the ones where I grew up to understand continuity and barriers and regular source of care.

So got some more time SAS programming, some more statistics, sort of learned the joy of writing papers and working with survey research and so went into medical school with a pretty strong intention of having research be a part of my future career. Then at Baylor in Houston and the Texas Medical Center, it's a wonderful place to train. We had a chance to do a global health track. And so I did that.

And my project was a group doing research on infectious disease prevention in energy workers. And it included a short trip to Russia, so that was kind of my foray into prevention research and global health. And that was shortly followed by two overseas fellowships. So I was a Fogarty Fellow. There's lots of Fogarty Fellows running around our institution.

But I was a Fogarty fellow placed in Saint Petersburg where my work was, again, infectious disease prevention in people with substance use disorder and so again with the prevention. That part was really, really stuck. And somewhere along the way, my Fogarty cohort had sent out another opportunity to stay overseas a bit longer. And so I applied for that and went to Zambia for a year with something called the Center for Infectious Disease Research in Zambia.

And there, we worked on some quality improvement research in the HIV care and treatment clinics, did some work with clinical trials, and also did some first experience qualitative research. We were doing some work with the workforce there to understand burnout, not just measuring the prevalence but also understanding really what it meant and how it materialized and what sort of influenced it.

So that was important because I continue to do a lot of qualitative and mixed methods research to this day. And that was really sort of the first part. To me, it was really a path into prevention research.

So when you're working in places where secondary and tertiary care are more challenging to access, you don't have an MGH down the road like I do, prevention is just that much more impactful. And so for me, it's always been a really meaningful place to work to help people stay healthy and keep them out of that hospital because it's not that close or easy to get to.

So I think that was kind of the path to prevention. And I think probably the other kind of common thread there is working with populations where medical care may be harder to reach, whether it's the rural US or global populations or marginalized populations, depending on what sites we were working with.

Oby: Thank you so much for sharing all of that and how it brought you to where you are today. And a lot of your work is shaped around implementation research. Would you provide us with a brief explanation of what that is? What is implementation research?

Gina Kruse: The definition I like for implementation research is getting the things that we know work from the science and the evidence into practice and doing it equitably so that it's actually there in the hands of the people that stand to benefit from it. Much of it revolves around this idea that it takes 14 years for data from an RCT to get into a clinical practice setting where somebody's going to benefit from it. So that's kind of my rough definition is like, how do we get things that we know work into people's hands so they can use them and make choices with that as part of their consideration, all that scientific evidence?

Oby: So you're the implementation lab director at the Implementation Science Center for Cancer Control Equity at the Harvard TH Chan School of Public Health. Can you talk about the work being done there and your role?

Gina Kruse: Yeah, happy to. And I also think-- like, I know I just said I'm not an implementation scientist, and yet I have this implementation lab director title. It sounds kind of funny. The Implementation Science Center for Cancer Control Equity, which we call ISCCCE for short, just so you don't have to-- it's a bit of a mouthful otherwise. So we call it ISCCCE.

Oby: Perfect.

Gina Kruse: It's a partnership between the Harvard TH Chan School of Public Health and investigators there, the MGH Kraft Center for Community Health and some other investigators around the institution, like people like me, and the Division of Gen-Med and the Mongan Institute at MGH. And we're partnering with the Mass League of Community Health Centers, which is the primary care association for federally-qualified health centers in Massachusetts.

We're partnering with them to try and create some infrastructure to be able to do community-engaged research and implementation science with community health centers. That infrastructure involves a lot of things that you need for research. It's like figuring out how data is shared and collected and how resources are shared. It develops the partnerships among all of the players.

And as the implementation lab director, I get to be a bit of a spoke, so trying to sort of make some connections and do some translation between the data collection and the research design and the people on the ground and the health centers and the administrative part of all this to sort of bring folks together to create some relationships. And a big part of that also is sort of trying to create some community between the community health centers as well as the investigators, our partners at the Mass League, around the topic of implementation science and cancer control and prevention.

The implementation lab does things like, one, sort of working to identify health center partners who would be a good fit for a specific topic, as well as working with the health center partners to identify what topics they care about and want to work on. We build community through an implementation learning community, which we do quarterly. It started during COVID, so it's been entirely virtual.

We just had one this month on health equity. It's both a forum for talking about topics together and a shared understanding of what this means for the health centers and how it might fit into implementation science. And it's also a space to disseminate results through the center.

So when we've done pilot studies and worked with folks, it's a place where we can share and talk through the meaning and the implications and interpretations so that things-- so the health equity learning community that we just had, for example, we shared some results of a set of interviews where one of our investigators sat down and spoke with community health center partners about what health equity is to them in their work, how it's operationalized, what are the challenges, what are their resources, what are the strengths they have to bring to the problem, and how do they think about it?

And then we could bring that together and talk and get some shared understanding of what that initial look at the data meant. The center is really set up to do community engaged research. And the learning communities are a space to have that sort of coming together and sharing and learning from each other.

Oby: Thank you. And I think you started to touch on this a bit. But you've talked about how your work connects with health care centers. What's the role of health care centers in the work that you do?

Gina Kruse: There's probably a couple of places here. I have other roles besides the Implementation Science Center for Cancer Control Equity, or ISCCCE. In ISCCCE, the connection is clear. So the health center partners really are-- we're trying to do community-engaged research where we work with health centers to answer implementation science questions that matter to them.

And so we've tried to set up systems to identify topics that they care about, to set up methods that fit within health centers, both leveraging the strengths that they bring, their knowledge of the community, the trust they have in their community, as well as some of the resource limitations that federally-qualified health centers face. So ISCCCE is working to do pilot studies with community health centers.

I think elsewhere, besides this cancer prevention stuff, the other big part of my research is tobacco cessation. And that's happened in a variety of settings that kind of align with that background story I gave up front. So I continue to do some global health, mostly on the topic of tobacco. So that works in community settings and practice settings.

And then I've also done some tobacco work with our Mass General Brigham affiliated community health centers as well. So yeah, community health centers continue to be a key partner in much of what I do. So it's not just the practice setting, but it's really meant to partner with the individuals in those organizations and the patients served by those organizations to have patient-centered, community-engaged work.

Oby: You just mentioned federally-qualified health centers. Can you define what a federally-qualified health care center is?

Gina Kruse: So I have been lucky to do some of my clinical work with some of the MGH-affiliated community health centers, which are similar to federally-qualified health centers and the patients that they serve and the services that they provide. But federally-qualified health centers are a unique definition. And they are community-based providers that receive money from HRSA to provide primary care services in underserved areas.

And they have a stringent set of requirements that includes things like having a sliding scale based on ability to pay to serving everyone who walks through the door and to have a governing board that includes the patients that they serve. And so they have these sort of strict requirements and this federal support. But they're really-- their mission is to be at the front line in these underserved areas and providing care for everybody. So there's sort of this special designation that's a little bit different from our MGH-affiliated community health centers.

Oby: Thank you for defining that for us. From what you've seen, what are some implementation strategies that work in health care centers?

Gina Kruse: I think the answer is it depends. In implementation science, we have this huge, big, long list of implementation strategies. There's facilitation. There's audit and feedback. There's reminders. There's changes in incentives and payment models. So there's this big, long list of strategies.

And I'm pretty sure they haven't all been tested in community health center settings but many have, and some work for some things and not for others. And it may not have anything to do with the health center in particular as much as, like, the fit of the strategy with the intervention for example.

It's definitely not a one size fits all working with the health centers. We've learned how important it is to have some co-development in what you're testing and what you're doing because you really need to find this combination of, with your strategy, what are sort of the key parts of the strategy that you need to do to be the strategy that you're trying to test? What are those sort of core functions that help define what it is? And then, what different formats can that take to fit into the different contexts and workflows of the different settings, health centers or other practice settings?

And so can this specific content be delivered in a couple of different ways? And either one of those is still holding true to what you think your strategy is. And I kind of described all that with regard to implementation strategies. For me, I think one of the very challenging things that you have to do upfront in implementation science projects is this exercise of mapping out what piece is what.

So core to implementation science, you have an evidence-based intervention or evidence-based treatment or something. So you have that. And then you have a strategy to try and get it to people. But it's not always entirely black and white what's the intervention and what's the strategy.

So if I'm doing a text message program to deliver behavioral support for tobacco cessation, is the text message the intervention, or is it the implementation strategy? And I think, for different studies, it could be either. So if it's an evidence-based package of a tobacco cessation texting program that's been tested against a standard control or something else, so you can say that in and of itself is an evidence-based intervention.

And then you want to have a strategy for how you get people to use it. So do you send out public health campaigns? Do you have their provider connect them into it when they're in the clinic? Those might be the strategies for implementing it.

On the other hand, the content that goes into those messages might be the evidence-based intervention. If it's delivering CBT, or Cognitive Behavioral Therapy, that might be the evidence-based intervention, and delivering it by text message is just one of a few options or strategies for getting it to people. It could be delivered by phone, through the patient portal, through in-person group meetings. And in that case, the texting itself might be the strategy as opposed to the intervention.

Again, like, I'm sure there's implementation scientists out here who would be like, no, you're not thinking of that right. But to me, like, sitting down and taking a minute to say, OK, what's the intervention and what delineates that from the strategy is a really important part upfront. And then you have to think about all these intricacies of the core functions for each of those things.

What are the core features of the intervention and the strategy? Which of them can be adapted to meet the specific needs of a community health center, populations, workflows, whatever, so that you have a clear idea of what it is we're trying to deliver? How it can be adapted or changed or modified to fit the local workflow, I think, is such a huge part of whether something works or not.

And having the space to do that kind of co-development and figure out, OK, here's the different forms it can take, here's what our workflows look like, what's going to fit for us? And is that still true to this intervention that you're trying to test or implement?

I think that sort of upfront work to delineate what it is you're doing, and it's sort of the downstream stuff is, OK, well, what are the outcomes to those different things? Like, what is the intervention outcome that you're looking at? What is the implementation strategy outcome that you're looking at?

The implementation strategy outcome for that texting example might be, how many people does the program reach? How many people get it and use it? That might be what you're comparing with an in-person model versus a texting model. What works and what doesn't? I think it just really depends on the project, the center, the intervention, so many different things.

But it's co-development and flexibility and really thinking upfront about what places you can be flexible to fit within your partner's workflows, I think, is a key to success in terms of what works. So it may not be a specific strategy but having that space to work together to fit it into their practice is important.

Oby: So you just talked about how the strategies that do and do not work in community health care centers are really tied to what works in the community and the local setting. So when you think about being someone who is academically trained and now working in community health care centers, how do you think about this community-engaged side of the work you do?

Gina Kruse: You know, I think for those of us who went along training to be clinician investigators, there's sort of this path you do that's often very quantitative. Some of us get some qualitative and mixed methods training along the way. But the thing that we don't often get that maybe is changing-- but I know it wasn't a huge part of my structured training getting to my current faculty position through fellowship and things like that-- was how to do community-engaged research and how to work with partners outside of the academic medical center or the integrated health care delivery system with a research unit, these institutions that were-- you know, we have all these amazing resources to make research possible like patient registries and IRBs and things like that.

But learning how to work with people outside of that kind of structure and world is so important if you want to have representative research and research that includes these populations most of us want to benefit from this work we're doing. But if you're not sort of partnering with them and understanding the different contexts, the communities, the cultures, I think you're going to be very challenged to have the influence that you want to have on those populations.

And community health centers are a special place to partner with. And I just feel so lucky that I have gotten to do some of this work with them and gotten to know lots of the folks out there and at the Mass League because they're really sort of this mission-driven, community-based set of health centers that have this amazing position within their community.

And they have so many strengths that I think really can take the research, particularly like implementation science and community-engaged research, to new places because they have these strengths and positions of trust and knowledge of their community that sometimes you get a little bit removed from working in kind of a big integrated health care delivery system. Not to say that our own integrated health care delivery system isn't community engaged. They really do a lot of great work working with their community health centers and community partners.

But I think federally-qualified health centers are a really unique kind of organization. And I just feel so lucky to have gotten to partner with them on this. And I think, for researchers who are interested in working with diverse populations and historically marginalized populations and all the kind of special populations that health centers work with, there may be space in our training programs and research fellowships to create some tools and some knowledge generation around how you build those partnerships.

And I think there's so much to learn. Even the science around how you create those sustainable relationships is an interesting space.

Oby: Well, thank you so much for joining us, Dr. Kruse. It's been a pleasure to have this conversation with you.

Gina Kruse: Thanks so much for having me. It's always a pleasure, Oby.

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