Improving therapist adoption of evidence-based practices with the LOCI strategy: a randomized controlled trial

Improving therapist adoption of evidence-based practices with the LOCI strategy: a randomized controlled trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Improving therapist adoption of evidence-based practices with the LOCI strategy: a randomized controlled trial Karina M Egeland, Randi Hovden Borge, Mark G Ehrhart, Gregory A Aarons, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7237246/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background : This study tested the effect of the Leadership and Organizational Change for Implementation (LOCI) strategy, aimed at helping leaders support and promote organizational change for implementation of evidence-based practice (EBP). The study aimed to evaluate the effects of LOCI on adoption, measured as (1) mental health therapists’ intentions to use assessment tools and EBPs for trauma, and (2) actual use of the EBPs, as indicated by patient recruitment for the EBP service. Methods : A stepped wedge cluster randomized design with three cohorts was conducted in Norwegian child and adult specialized mental health clinics implementing trauma assessment tools and one of three EBPs for trauma treatment. Therapists (n=790) received training in assessment tools, and a subgroup (n=301) received training in one of three EBPs. At the same time, a first cohort of leaders (n=16) began the one-year LOCI strategy, with cohorts 2 (n=14) and 3 (n=17) starting four and eight months later, respectively. Surveys included measures of intentions to implement trauma assessment tools and the EBP for trauma treatment, and were conducted at baseline, 4, 8, 12, 16, and 20 months. Actual use was measured by therapists’ recruitment of patients for treatment. To examine LOCI’s effect on therapists’ intentions, linear mixed-effects models were performed. To examine differences in recruitment status across the three cohorts, a logistic regression and a negative binominal regression were performed. Results : Across the three cohorts, therapists’ intentions to use trauma assessment tools increased significantly when the LOCI strategy was introduced. Intentions to use the trauma treatment methods were high from the start, and did not increase significantly when LOCI was introduced. Patient recruitment differed among cohorts. Therapists in cohort 3 recruited significantly fewer patients than those in cohort 1. Additionally, significantly fewer therapists in cohort 3 had recruited at least one patient than those in cohort 1 and 2. Conclusions : LOCI effectively increased therapists' EBP adoption, emphasizing the importance of early leadership engagement in enhancing uptake of new EBPs. Findings suggest that delayed leadership engagement after EBP training may hinder implementation. Timely support from leaders is crucial for therapists to implement new practices. Trial registration: ClinicalTrials NCT03719651, 5th of July 2018. The trial protocol can be accessed from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6417075/ adoption implementation leadership implementation strategy LOCI posttraumatic stress disorder Figures Figure 1 Contributions to the literature This study contributes to the growing evidence for the effectiveness of the LOCI strategy by demonstrating its impact on therapists’ adoption of EBPs in mental health clinics. By examining therapists' intentions and patient recruitment as proxies for adoption, the study provides insights into the potential mechanisms driving implementation success. The findings emphasize the importance of early leadership engagement in the implementation process, and the need for a robust preparation phase in implementation efforts to improve implementation outcomes. Further research is needed to better understand which parts of the LOCI strategy are most effective in driving long-term implementation success. Background Successfully integrating evidence-based practices (EBPs) into mental health care requires the identification and execution of several implementation strategies. Research shows that, without a well-defined approach, even the most effective EBPs often fail to become institutionalized in clinical practice (i.e., those who directly supervise therapists and frontline service providers, 1). In this process, leaders play a pivotal role, as they are responsible for guiding and aligning efforts across different levels of the organization ( 2 – 4 ). Leadership and Organizational Change for Implementation (LOCI) is a multifaceted implementation strategy aimed at strengthening leaders’ capacity to guide the uptake and continued use of EBPs among staff ( 5 – 7 ). LOCI draws on two leadership theories: (i) full-range leadership emphasising general transformational leadership behaviours ( 8 ), and (ii) implementation leadership ( 9 ), which highlights proactive, knowledgeable, supportive, and perseverant leadership aimed specifically at EBP implementation. Further, it draws on the theory of organizational implementation climate ( 10 ), which emphasizes how leaders can create a context in which the use of EBPs is expected, supported, and valued. LOCI is grounded in the EPIS framework, which outlines four key phases of EBP implementation: Exploration, Preparation, Implementation, and Sustainment ( 11 , 12 ). During LOCI, the focus is primarily on inner organizational context, and the preparation and implementation phases ( 5 ). LOCI has a focus on supporting first-level leaders (i.e., those who directly supervise therapists and frontline service providers; 13), while also engaging executive leaders to ensure first-level leaders are effectively supported. This dual-level approach aims to cultivate an implementation climate that facilitates the adoption and use of EBPs ( 13 ). LOCI is grounded in the hypothesis that by strengthening the implementation climate within clinical units, leaders can increase therapists’ engagement in implementation processes, thereby promoting successful implementation and, ultimately, improving patient outcomes ( 6 ). The results from studies on LOCI are promising. The strategy has been tested in six randomized controlled trials (RCTs) across diverse mental health settings ( 5 , 7 , 14 – 16 ). These studies have found LOCI to be related to significantly improved implementation leadership and implementation climate ( 15 , 17 , 18 ), as well as therapists’ implementation citizenship behaviors ( 5 ). LOCI has also demonstrated positive effects on therapist fidelity ( 14 , 15 ), reach ( 5 ), and patient outcomes ( 14 ). Findings related to full-range leadership ( 5 , 17 ) and the maintenance of outcomes over time have been somewhat mixed ( 5 , 19 ). LOCI is a complex implementation strategy involving multiple interacting processes and mechanisms, many of which are not yet fully understood. Ongoing research aims to further explore these mechanisms ( 20 ). Evidence-based trauma treatment Post-traumatic stress disorder (PTSD) is a serious mental health condition that can develop after exposure to trauma, and is linked to significant impairment in daily functioning and quality of life ( 21 ). There are several EBPs for PTSD ( 22 ), yet implementing them can often be challenging ( 23 ). Studies of implementation of trauma treatment in routine clinical practice are in demand ( 21 ). The current study was part of an ongoing national implementation of EBPs for PTSD, funded by the Norwegian Ministry of Health and Care Services, and implemented by the Norwegian Centre for Violence and Traumatic Stress Studies ( 16 ). The EBPs for trauma treatment were Trauma-Focused Cognitive Behavioral Therapy (TF-CBT; 24) in child clinics, and Cognitive Therapy for PTSD (CT-PTSD; 25) and Eye Movement Desensitization and Reprocessing (EMDR; 26) in adult clinics. The clinics were divided into three cohorts. All clinics received training in assessment tools and EBPs for trauma at the same time, while the three cohorts began participating in the LOCI strategy at different time points. As a result, each clinic had a control period (non-LOCI), followed by a LOCI period. This design led to some clinics (cohort 1) receiving training in EBPs for trauma simultaneously with the start of LOCI, while others had a delayed LOCI start (cohorts 2 and 3). Assuming that leaders provide better follow-up and support to staff when they participate in LOCI, it is reasonable to expect that therapists in cohort 1 would begin using the assessment tools and methods more quickly and to a greater extent than those in cohorts with a delayed LOCI start. The goal of this study was to investigate the effect of LOCI on therapists’ adoption, defined as “the intention, initial decision, or action to try or employ an innovation or evidence-based practice” ( 27 ). Adoption was measured as ( 1 ) therapists’ intentions to use trauma assessment tools and the EBP for trauma treatment, and ( 2 ) their action in employing these treatment methods, as indicated by recruiting patients into the study. The following hypotheses were examined: H1a) Therapists’ intentions to use trauma assessment tools will be significantly higher in the LOCI vs. control condition. H1b) Therapists’ intentions to use the EBP for trauma treatment will be significantly higher in the LOCI vs. control condition. H2) Therapists in clinics that began LOCI concurrently with training in EBPs will use the EBPs significantly more than clinics with a delayed LOCI start. In the protocol of the overall study, additional hypotheses were pre-specified ( 16 ). See the appendix for analyses and results of additional hypotheses. Methods A stepped wedge study with three cohorts was conducted between 2018 and 2020 to examine the effect of the LOCI strategy. See study protocol for further details ( 16 ). The StaRI checklist was used as reporting standard ( 28 ). Participants Forty-three child and adult specialized mental health outpatient clinics throughout Norway implemented assessment tools and EBPs for trauma exposure and PTSD between 2018 and 2020. Forty-seven first-level leaders within the clinics participated in LOCI. The leaders were mostly female (62%), psychologists (55%), with the average age of 55 (range 41–70) (Table 1 ). Table 1 Participant characteristics LOCI leaders (N = 47) Therapists (N = 790) Gender Women Men Missing 29 18 - (61.7%) (38.3%) 597 168 25 (78%) (22%) Education Psychology Medicine Social worker Nursing Other Missing 26 5 8 8 - - (55.3%) (10.6%) (17.0%) (17.0%) 367 149 56 55 89 74 (51.3%) (20.8%) (7.8%) (7.7%) (12.4%) Age Missing 54.7 - (SD = 7.64) - 48.9 109 (SD = 11.1) Therapists (n = 790) from the abovementioned clinics participated in the study. Therapists in all the clinics received training in assessment tools in the beginning of the project period, and a subgroup (n = 301) received training in PTSD treatment methods. Most therapists were female (76%), psychologists (47%), and the average age was 49 (range 31–80) (Table 1 ). Procedures An open invitation was sent out to outpatient clinics throughout Norway, and 43 child and adult clinics volunteered to join. In child mental health clinics, the implementation had been ongoing since 2012, covering about half of the clinics in Norway at the time of the current study. In adult clinics, this was the first implementation round. The clinics in the current study had previously not participated in the EBP implementation. All therapists received 3 hours of training in assessment tools. For the PTSD treatment methods, clinic leaders were advised to select therapists who were motivated for training and who planned to remain in the clinic over time. A subgroup of therapists participated in a three-day course in a specific PTSD treatment method (CT-PTSD, EMDR, or TF-CBT), followed by coaching by specialists in the EBPs. The adult clinics received 10 hours of group coaching, while the child clinics received weekly group coaching (about 40 hours). Therapists in adult clinics were asked to recruit at least three patients each into the study to ensure sufficient practice. Therapists in child clinics were asked to recruit at least one patient, gradually increasing the number as they became more familiar with the method. Due to staff turnover throughout the implementation period, all clinics were offered to have more therapists trained in both 2019 and 2020 (Table 2 ). Table 2 Therapist training and patient recruitment Cohort 1 Cohort 2 Cohort 3 Total Trained in screening tools 790 Trained in treatment methods TF-CBT EMDR CT-PTSD 104 (35%) 90 (30%) 107 (35%) 301 116 (39%) 97 (32%) 87 (29%) No. of recruited patients TF-CBT EMDR CT-PTSD 191 (40%) M = 1.84 (0–6) 103 (54%) 56 (29%) 32 (17%) 152 (31%) M = 1.71(0–7) 61 (40%) 54 (36%) 37 (24%) 141 (29%) M = 1.32 (0–12) 52 (37%) 42 (30%) 47 (33%) 484 216 (45%) 152 (31%) 116 (24%) Therapists with no recruitments TF-CBT EMDR CT-PTSD 31 (29%) 15 (42%) 6 (16%) 10 (29%) 26 (24%) 7 (19%) 12 (32%) 7 (21%) 50 (47%) 14 (39%) 19 (52%) 17 (50%) 107 36 (33.5%) 37 (34.5%) 34 (32%) 2018 2019 2020 Time trained 203 80 18 301 The clinics were randomized into one of three cohorts representing the timepoint when leaders would begin their engagement in the LOCI strategy. The first cohort began at baseline, concurrently with the EBP training (16 leaders). The second cohort began 4 months after the EBP training (14 leaders), and the third cohort 8 months after the EBP training (17 leaders). Participation in LOCI was one year for all three cohorts (see Supplementary Material for participant flow). The LOCI training consisted of five days of training (2 days of training when beginning LOCI, and one day of training every quarter thereafter). During these trainings, the first-level leaders (hereafter called LOCI leaders) were introduced to general and strategic leadership principles and implementation climate. They also received results from 360° assessments of their leadership and the clinic’s climate. Based on these results, they developed individualized leadership development plans. The leaders had weekly coaching calls by phone with a LOCI facilitator to discuss their progress on the leadership plans. Once a month, this individual coaching call was replaced with group coaching calls for all LOCI leaders within the cohort. To promote leadership alignment, executive leaders were actively involved in the LOCI process. After each LOCI training session, Organizational Strategy Meetings (OSMs) were held, involving LOCI leaders, executive leaders, and other key staff members. These meetings were organized by health trust: when multiple clinics from the same trust participated, joint OSMs were conducted with one executive leader, several LOCI leaders, and relevant central staff. When only one clinic from a trust participated, the OSM included one executive leader, one LOCI leader, and other central staff members. During these meetings, aggregated data on the implementation climate were shared, and climate development plans were co-created to outline the steps the organization would take to support EBP implementation. These plans were tailored over time to respond to emerging challenges, organizational needs, and new opportunities. To ensure continued progress and follow-up, executive leaders also participated in monthly 30-minute individual phone calls, where they discussed and monitored the advancement of their climate development plans. Leaders and therapists completed surveys at baseline, and after 4, 8, 12, 16, and 20 months (T0-T5). Measures The Measure of Innovation-Specific Implementation Intention (MISII) was used to measure therapists’ intentions to implement the EBPs for PTSD ( 29 ). The MISII consists of three items that each capture an aspect of intention: plans, desire, and scope. The MISII was adapted for this project to measure therapists’ intentions to implement a) the trauma assessment tools (intent to assess) , and b) the specific EBP (intent to treat) . The items were rated on a 5-point scale from 0 (“not at all”) to 4 (“a very great extent”). The Cronbach's alpha ranged from 0.95 to 0.96 for the different time points (T0-T5), indicating excellent internal consistency. Therapists’ use of the trauma EBP was assessed as indicated by their recruitment of patients for treatment. Specifically, recruitment was assessed as a) whether the trained therapists recruited any patients into the project, b) how many they recruited during the project period, and c) the length of time to recruit their first patient following the trauma treatment training. Analyses To examine LOCI’s effect on therapists’ intentions, linear mixed-effects models were performed. These models account for data dependency, accommodate irregular measurement intervals ( 30 ), and can handle missing data ( 31 ). The models included fixed effects representing change before and during the LOCI intervention, and random effects to account for variability between clinics and between therapists in both intercept and slope. The random structure was simplified when necessary to ensure model stability ( 32 ). In supplementary analyses, categorical variables were added to examine differences between cohorts and clinic types (child versus adult). An immediate increase in the outcome at the start of LOCI, reflected by an initial shift in the intercept, would be interpreted as the immediate effect of LOCI. A positive value would indicate improvement. A steeper upward slope following LOCI would suggest that the intervention's effect continued to grow over time after the commencement of LOCI. There were 2.3% missing data for the MISII assessment tools, and 19% for the MISII treatment methods. Missing data were excluded listwise at the item level: if two out of three items for a given measure were missing, that specific measure was excluded from the analysis for that case. To assess the internal validity of the MISII, Cronbach’s alpha was calculated. To examine differences in recruitment status (yes/no) across the three cohorts, a logistic regression was performed. Differences in the number of patients recruited were assessed using negative binominal regression. To compare cohorts 2 and 3 directly, the reference category was changed and the regression models re-estimated. Time from training to first patient recruitment was analyzed with Kaplan–Meier estimators. Robust standard errors and 95% confidence intervals were calculated for the logistic regression, negative binomial regression, and Kaplan–Meier survival analyses to account for non-independence and clustering (i.e., therapists within clinics). All analyses were performed in R ( 33 ). The nlme package ( 34 ) was used for linear mixed-effects modeling. Internal consistency analyses used the psych package ( 35 ). Data were subsetted by measurement time points (T0-T5) using dplyr ( 36 ). Logistic and negative binomial regressions were performed using glm and glm.nb from the MASS package ( 37 ). Time-to-event analyses were conducted using the survfit function ( 38 ) and plotted with ggsurvplot from the survminer package ( 39 ). Results Intentions to use trauma assessment tools When LOCI was introduced, there was a significant increase in therapists’ intentions to use assessment tools compared to the control period (Table 3 ). While there was no significant trend in therapists’ intentions before LOCI were introduced, there was a small, but significant increase in the slope in the LOCI period. Table 3 The effect of LOCI based on mixed effects analyses Effect Estimate 95% CI P LL UP Intentions to use trauma assessment tools Value when LOCI starts Non-LOCI 2.59 2.42 2.77 < .001 LOCI 3.00 2.87 3.12 < .001 Difference LOCI non-LOCI 0.41 0.26 0.55 < .001 Slope Non-LOCI 0.05 -0.03 0.13 0.200 LOCI 0.08 0.04 0.12 < .001 Difference LOCI non-LOCI -0.03 -0.11 0.06 0.542 Intentions to use treatment methods Value when LOCI starts Non-LOCI 2.81 2.59 3.02 < .001 LOCI 2.95 2.82 3.07 < .001 Difference LOCI non-LOCI 0.14 -0.06 0.34 0.177 Slope Non-LOCI -0.11 -0.22 0.01 0.069 LOCI -0.03 -0.07 0.02 0.177 Difference LOCI non-LOCI -0.08 -0.20 0.04 0.203 There was a statistically significant difference in LOCI's effect between adult and child clinics (three-way interaction: coefficient = -0.295, p < .001). Adult clinics demonstrated a small negative, but not significant slope prior to LOCI (coefficient = -0.04, p = 0.432). At the introduction of LOCI, there was a significant increase in therapists’ intentions (coefficient = 0.46, p < .001), and the post-LOCI slope was significantly positive (coefficient = 0.08, p < .001). In contrast, child clinics demonstrated a significant positive slope prior to LOCI (coefficient = 0.21, p < .001). When LOCI was introduced, child clinics, like adult clinics, had a significant increase in therapists’ intentions (coefficient = 0.29, p = .004). Following LOCI introduction, it continued on a positive slope (coefficient = 0.06, p = 0.017), but significantly declined in magnitude (coefficient = -0.15, p = 0.015). Intentions to use EBPs Regarding therapists’ intentions to implement the EBP, there was no significant difference between LOCI and non-LOCI in either value at the transition or rate of change over time. Therapists’ intentions were high at baseline, as reflected in the elevated initial scores across both groups (Table 3 and Fig. 1 ), and stayed high over time. Use of EBPs The number of recruited patients per therapist after receiving EBP training is shown in Table 2 . A negative binominal regression examining recruitment across cohorts showed that therapists in cohort 3 recruited significantly fewer patients than those in cohort 1 (IRR = 0.72, 95% CI [0.52, 0.99], p = 0.043). There was no significant difference between cohort 2 and 1 (IRR = 0.92, 95% CI [0.71, 1.19], p = 0.529), nor between cohort 2 and 3 (IRR = 0.78, 95% CI [0.56, 1.08], p = 0.139). A logistic regression showed that significantly fewer therapists in cohort 3 recruited patients than those in cohort 1 (OR = 0.48, 95% CI [0.27, 0.85], p = 0.012) and 2 (OR = 0.49, 95% CI [0.27, 0.88], p = 0.017). There was no sigificant difference between cohorts 1 and 2 (OR = 0.99, 95% CI [0.54, 1.84], p = 0.977). Kaplan-Meier survival analysis using Cox proportional hazards regression showed no significant differences between cohorts regarding time from trauma treatment training to first patient recruitment (Wald test: χ²( 2 ) = 0.18, p = 0.90). HR for cohort 2 vs. 1: 0.94, 95% CI [0.62, 1.42]; HR for cohort 3 vs. 1: 1.03, 95% CI [0.70, 1.51]. Additional analyses of secondary hypotheses are presented in the Appendix. Briefly, no significant effects of LOCI were found on therapists’ job demands or implementation citizenship behavior (ICB), although ICB increased during the control period. Discussion This study demonstrated that leaders’ participation in the LOCI strategy had a significant impact on therapists’ adoption. There was a significant increase in adoption when LOCI was introduced, and we assume that this effect was driven by leaders applying leadership and climate-embedding strategies as part of the LOCI strategy ( 40 ). These strategies may have enhanced therapists’ intentions to use trauma assessment tools. Furthermore, clinics where leaders began their participation in LOCI concurrently with therapists’ training in the EBPs (cohort 1) showed higher rates of patient recruitment compared to clinics where leaders began their participation in LOCI four or eight months after therapists received their training. These findings suggest that early leadership engagement may support therapists in adopting the methods, possibly through demonstrating commitment to the implementation and sustainment of EBPs ( 41 ). In contrast, delayed leadership involvement following the start of implementation may lead to poorer implementation outcomes. There was a significant difference in the pre-LOCI slope regarding intentions over time between child and adult clinics. Following EBP training but prior to engagement in LOCI, therapists in child clinics demonstrated a significant rate of increase in their intentions to use trauma assessment tools, whereas the levels of intentions among therapists in adult clinics was flat. After the start of LOCI, the pattern was similar across child and adult clinics; there was a significant jump in the intentions at the start of LOCI and a similar significant, positive slope after LOCI. Thus, the primary difference between the child and adult clinics was how therapist intentions changed over time after the initial EBP training. The implementation of trauma assessment tools and treatment methods has been ongoing in Norwegian child clinics since 2012. This longstanding practice may have influenced the participating clinics, as it has become increasingly common to assess for trauma and PTSD in specialized child mental health clinics. Although the participating clinics had not previously received training in systematic assessment, several of them already used the assessment forms. Consequently, the training may have served more as a reminder in child clinics for practices partly established. In contrast, in adult specialized mental health clinics, this represented the first implementation round, where assessing for trauma and PTSD had not been previously emphasized. Regardless, the results demonstrated a significant increase when leaders participated in LOCI, highlighting the importance of leaders taking the lead and paving the way for therapists’ intentions. It is important to note that intentions do not equate to actual usage, but rather are considered an assumed prerequisite for adoption ( 29 , 42 , 43 ). Similarly, we do not know if patient recruitment into the research study reflected actual usage within the services. However, this could not be measured as Norwegian healthcare services lack systems for recording assessment and method usage. Nonetheless, investigating therapists’ intentions and their recruitment into the research study serves as a useful proxy and provides insight into potential adoption and utilization of new tools and methods. There were no statistically significant findings related to therapists’ intentions to use the treatment methods. However, statistical power was low, meaning that small true differences may have gone undetected. Furthermore, no significant differences were found between cohorts in the time from training to first patient recruitment. Nevertheless, the sample consisted of a self-selected group of therapists with a high level of motivation and strong intentions to learn and use trauma-focused treatments from the outset. It might be that leaders’ participation in LOCI may be less impactful for this smaller group of motivated therapists during the initial learning phase. At the same time, in the long run, the absence of leadership support during training may hinder sustained implementation if therapists do not begin using the methods in practice, as suggested by the recruitment data. This, in turn, could impede the institutionalization of the newly gained knowledge. The findings of this study add to the growing body of evidence supporting the effectiveness of LOCI. However, there were also null findings regarding LOCI’s impact on job demands and implementation citizenship behavior (see Appendix), indicating mixed results compared to previous studies ( 5 ). LOCI is a complex, multi-component strategy, and further research is needed to identify which elements drive its effects. In this study, LOCI was initiated concurrently with, or shortly after, training in trauma assessment tools and treatment methods. However, more recent studies highlight the importance of a robust preparation phase to ensure readiness for implementation ( 44 ). It may therefore be beneficial to initiate LOCI earlier to allow more time for preparatory activities. It should also be noted that all participating clinics joined voluntarily, which involved mandatory participation in LOCI. This may limit the generalizability of the findings to clinics where participation is less voluntary. Conclusions The study underscores the importance of early leadership engagement in the LOCI strategy, which significantly enhanced therapists' intentions to use trauma assessment tools and increased patient recruitment rates. Clinics with concurrent leadership and therapist EBP training showed better outcomes, illustrating the need for early leadership engagement in facilitating method adoption. Although intentions and recruitment are not equivalent to actual use, the findings highlight potential adoption patterns. Further research is needed to identify key elements of LOCI that support sustained implementation. Abbreviations LOCI Leadership and Organizational Change for Implementation EBP Evidence-Based Practices PTSD Post-Traumatic Stress Disorder Declarations Ethics approval and consent to participate The study was approved by the Norwegian Centre for Violence and Traumatic Stress Studies (NKVTS), which is responsible for data processing. A data protection impact assessment was reviewed and assessed by SIKT – the Norwegian Agency for Shared Services in Education and Research (NSD 60036/3/LH, NSD 60059/3/OOS). The study is registered in ClinicalTrials NCT03719651, 25th of October 2018. Informed consent was obtained from all relevant participants. Consent for publication Not applicable Funding The implementation project was funded by the Norwegian Ministry of Health and Care Services. The funders had no role in planning, designing, and analyzing the results. Authors’ contributions AMSS and KME were responsible for all parts of the study. KME, RHB, NB, and TWL participated in the preparation of data files and the execution of analyses. NP, HB, and ME helped with planning and coordinating the study and data collection. MGE, MS, and GAA contributed to the conception and design of the study. KME had primary responsibility for writing the manuscript. All authors contributed to the writing of the manuscript and approved the final version. Acknowledgements We gratefully acknowledge the participating leaders, therapists, supervisors, and other staff for collaborating with us and providing data for this study. Availability of data and materials The datasets will be available from the corresponding author on reasonable request. LOCI training materials are the property of Behavioral Change Consulting. Competing interests GAA is co-Editor-in-Chief of Implementation Science and on the editorial board of Implementation Science Communications . All decisions about this paper were made other editors. References Fontaine G, Vinette B, Weight C, Maheu-Cadotte M-A, Lavallée A, Deschênes M-F, et al. Effects of implementation strategies on nursing practice and patient outcomes: a comprehensive systematic review and meta-analysis. Implement Sci. 2024;19(1):68. Meza RD, Triplett NS, Woodard GS, Martin P, Khairuzzaman AN, Jamora G, et al. The relationship between first-level leadership and inner-context and implementation outcomes in behavioral health: a scoping review. Implement Sci. 2021;16(1):1–21. Ehrhart MG, Aarons GA, Alignment. Impact on implementation processes and outcomes. Implementation Science: Routledge; 2022. pp. 171–4. Aarons GA, Farahnak LR, Ehrhart MG, Sklar M. Aligning Leadership Across Systems and Organizations to Develop Strategic Climate to for Evidence-Based Practice Implementation. Annu Rev Public Health. 2014;35:255–74. Aarons G, Sklar M, Ehrhart MG, Roesch S, Moullin JC, Carandang K. Randomized trial of the leadership and organizational change for implementation (LOCI) strategy in substance use treatment clinics. J Subst Use Addict Treat. 2024;165:209437. Aarons GA, Ehrhart MG, Moullin JC, Torres EM, Green AE. Testing the leadership and organizational change for implementation (LOCI) intervention in substance abuse treatment: a cluster randomized trial study protocol. Implement Sci. 2017;12(1):29. Aarons GA, Ehrhart MG, Farahnak LR, Hurlburt MS. Leadership and organizational change for implementation (LOCI): a randomized mixed method pilot study of a leadership and organization development intervention for evidence-based practice implementation. Implement Sci. 2015;10:11. Bass BM. From transactional to transformational leadership: Learning to share the vision. Organ Dyn. 1990;18(3):19–31. Aarons GA, Ehrhart MG, Farahnak LR. The Implementation Leadership Scale (ILS): development of a brief measure of unit level implementation leadership. Implement Sci. 2014;9(1):45. Ehrhart M, Aarons GA, Farahnak LR. Assessing the organizational context for EBP implementation: the development and validity testing of the Implementation Climate Scale (ICS). Implement science: IS. 2014;9:157. Moullin JC, Dickson KS, Stadnick NA, Rabin B, Aarons GAJIS. Systematic review of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. Implement Sci. 2019;14(1):1. Aarons GA, Hurlburt M, Horwitz SM. Advancing a conceptual model of evidence-based practice implementation in public service sectors. Adm Policy Mental Health Mental Health Serv Res. 2011;38(1):4–23. Priestland A, Hanig R. Developing first-level leaders. Harvard Business Rev. 2005;83(6):112–20. 50. Williams NJ, Marcus SC, Ehrhart MG, Sklar M, Esp SM, Carandang K, et al. Randomized Trial of an organizational implementation strategy to improve measurement-based Care Fidelity and Youth outcomes in Community Mental Health. Journal of the American Academy of Child & Adolescent Psychiatry; 2023. Brookman-Frazee L, Lau AS, Roesch SC, Jobin A, Chlebowski C, Mello M, et al. Effectiveness of Multilevel Implementation Strategies for Autism Interventions: Outcomes of Two Linked Implementation Trials. Journal of the American Academy of Child & Adolescent Psychiatry; 2025. Egeland K, Skar A-MS, Endsjø M, Laukvik EH, Bækkelund H, Babaii A, et al. Testing the leadership and organizational change for implementation (LOCI) intervention in Norwegian mental health clinics: a stepped-wedge cluster randomized design study protocol. Implement Sci. 2019;14(1):28. Skar A-MS, Braathu N, Peters N, Bækkelund H, Endsjø M, Babaii A et al. A stepped-wedge randomized trial investigating the effect of the Leadership and Organizational Change for Implementation (LOCI) intervention on implementation and transformational leadership, and implementation climate. BMC Health Serv Res 2022;22(298). Williams NJ, Ehrhart MG, Aarons GA, Esp S, Sklar M, Carandang K, et al. Improving measurement-based care implementation in youth mental health through organizational leadership and climate: a mechanistic analysis within a randomized trial. Implement Sci. 2024;19(1):29. Williams NJ, Aarons GA, Ehrhart MG, Esp S, Vega N, Sklar M et al. Effects of an Organizational Implementation Strategy on Sustainment of Measurement-Based Care in Community Mental Health. Psychiatric services. 2025:appi. ps. 20240302. Locke J, Corbin CM, Collins VK, Ehrhart MG, Goosey R, Hatch K, et al. Helping Educational Leaders Mobilize Evidence (HELM): The iterative redesign of the Leadership and Organizational Change for Implementation (LOCI) intervention for use in schools. Implement Res Pract. 2024;5:26334895241242523. Olff M, Hein I, Amstadter AB, Armour C, Skogbrott Birkeland M, Bui E, et al. The impact of trauma and how to intervene: a narrative review of psychotraumatology over the past 15 years. Eur J Psychotraumatology. 2025;16(1):2458406. NICE. Post-traumatic stress disorder. NICE guideline. 2018. Pfeiffer E, Unterhitzenberger J, Enderby P, Juusola A, Kostova Z, Lindauer RJ, et al. The dissemination and implementation of trauma-focused cognitive behavioural therapy for children and adolescents in seven European countries. BMC Health Serv Res. 2024;24(1):1202. Cohen JA, Mannarino AP, Deblinger E. Treating trauma and traumatic grief in children and adolescents. New York, NY: Guildford; 2006. Ehlers A, Clark DM. A cognitive model of posttraumatic stress disorder. Behav Res Ther. 2000;38(4):319–45. Shapiro F, Laliotis D. EMDR Therapy for Trauma-Related Disorders. In: Schnyder U, Cloitre M, editors. Evidence Based Treatments for Trauma-Related Psychological Disorders: A Practical Guide for Clinicians. Cham: Springer International Publishing; 2015. pp. 205–28. Proctor EK, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Mental Health Mental Health Serv Res. 2011;38(2):65–76. Pinnock H, Barwick M, Carpenter CR, Eldridge S, Grandes G, Griffiths CJ, et al. Standards for Reporting Implementation Studies (StaRI) Statement. BMJ. 2017;356:i6795. Moullin JC, Ehrhart MG, Aarons GA. Development and testing of the Measure of Innovation-Specific Implementation Intentions (MISII) using Rasch measurement theory. Implement Sci. 2018;13(1):89. Gibbons RD, Hedeker D, DuToit S. Advances in analysis of longitudinal data. Ann Rev Clin Psychol. 2010;6:79–107. Matuschek H, Kliegl R, Vasishth S, Baayen H, Bates D. Balancing Type I error and power in linear mixed models. J Mem Lang. 2017;94:305–15. Pinheiro J, Bates D. Mixed-effects models in S and S-PLUS. Springer Science & Business Media; 2006. R Core Team. R: A language and environment for statistical computing. R Foundation for Statistical Computing. editor. Vienna, Austria: R Foundation for Statistical Computing; 2021. Pinheiro JC. nlme: linear and nonlinear mixed effects models. R package version 3.1–98. In: Pinheiro JC, editor. https://cran.r-project.org/web/packages/nlme/index.html 2011. Revelle W. psych: Procedures for Personality and Psychological Research. 1.5.4 ed. Evanston. Illinois, USA: Northwestern University; 2015. Wickham H, François R, Henry L, Müller K, Vaughan D. dplyr: A Grammar of Data Manipulation. R package version 1.1.4. https://dplyr.tidyverse.org 2025. Venables WN, Ripley BD. Modern Applied Statistics with S. 4th ed. Springer; 2002. R Development Core Team. survival: Survival Analysis. R package version 3.5-5. 2023. Kassambara A, Kosinski M, Biecek P, survminer. Drawing Survival Curves using \'ggplot2\'. R package version 0.5. 2024. Schein EH. Organizational culture and leadership. San Fransisco, CA: Wiley; 2010. Stetler CB, Ritchie JA, Rycroft-Malone J, Charns MP. Leadership for evidence‐based practice: strategic and functional behaviors for institutionalizing EBP. Worldviews Evidence‐Based Nurs. 2014;11(4):219–26. Damschroder LJ, Reardon CM, Opra Widerquist MA, Lowery J. Conceptualizing outcomes for use with the Consolidated Framework for Implementation Research (CFIR): the CFIR Outcomes Addendum. Implement Sci. 2022;17(1):7. Williams NJ. Assessing mental health clinicians’ intentions to adopt evidence-based treatments: reliability and validity testing of the evidence-based treatment intentions scale. Implement Sci. 2016;11(1):60. Alley ZM, Chapman JE, Schaper H, Saldana L. The relative value of Pre-Implementation stages for successful implementation of evidence-informed programs. Implement Sci. 2023;18(1):30. Supplementary Files StaRIchecklist.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 01 Feb, 2026 Reviewers agreed at journal 07 Oct, 2025 Reviewers invited by journal 03 Sep, 2025 Editor assigned by journal 30 Jul, 2025 First submitted to journal 28 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7237246","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":509986536,"identity":"5aac152c-ea11-46e7-b7a6-29b8a9439c9a","order_by":0,"name":"Karina M Egeland","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBUlEQVRIiWNgGAWjYBACCSA+AGEyNzAwsNmARYjVwgjSkgYUYSashQFJy2HCWiTbzz48XFDDICfv3tj4uaDsfJ7kjPzDHxh32ODUIs2TbnB4xjEGY8MzB5ulZ5y7XSwtkcwmwXgmDacWOYY0hsM8bAyJG2ckNkjztt1OnMdzmI2Bse0wbi38z4Ba/jHUb5z/sPk3b9s5kBbmD/i0SEsAbeFtY0iQl2BsA9pyIHE2ezODBD4tkjOAtvD2SRhu4Elss+Y5l5w4s73ZTCKxDbdfJM6nMX/m+WYjL99++PBtnjK7xBmHGR9/+NiGO8RgOhkMDiDzEwhpAAH5BmJUjYJRMApGwYgEAF1cUI4pvV6dAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0002-6757-4696","institution":"The Norwegian Centre for Violence and Traumatic Stress Studies","correspondingAuthor":true,"prefix":"","firstName":"Karina","middleName":"M","lastName":"Egeland","suffix":""},{"id":509986537,"identity":"33896a65-f2c1-464e-a94b-ae77d40fbb86","order_by":1,"name":"Randi Hovden Borge","email":"","orcid":"","institution":"National Institute of Occupational Health","correspondingAuthor":false,"prefix":"","firstName":"Randi","middleName":"Hovden","lastName":"Borge","suffix":""},{"id":509986538,"identity":"19763cf2-b071-40b1-96df-f0077169cea4","order_by":2,"name":"Mark G Ehrhart","email":"","orcid":"","institution":"University of Central Florida, Department of Psychology","correspondingAuthor":false,"prefix":"","firstName":"Mark","middleName":"G","lastName":"Ehrhart","suffix":""},{"id":509986539,"identity":"961a94b9-6586-4856-b724-ddd43c3b5899","order_by":3,"name":"Gregory A Aarons","email":"","orcid":"","institution":"University of california San Diego, Department of Psychiatry","correspondingAuthor":false,"prefix":"","firstName":"Gregory","middleName":"A","lastName":"Aarons","suffix":""},{"id":509986540,"identity":"ce8e17b7-6442-411f-ba75-85e45e9ee85c","order_by":4,"name":"Marisa Sklar","email":"","orcid":"","institution":"University of california San Diego, Department of Psychiatry","correspondingAuthor":false,"prefix":"","firstName":"Marisa","middleName":"","lastName":"Sklar","suffix":""},{"id":509986541,"identity":"0b4a41a5-9c96-4df3-8ba3-5abba43a25a3","order_by":5,"name":"Nora Braathu","email":"","orcid":"","institution":"The Norwegian Centre for Violence and Traumatic Stress Studies","correspondingAuthor":false,"prefix":"","firstName":"Nora","middleName":"","lastName":"Braathu","suffix":""},{"id":509986542,"identity":"2b704624-a00b-478f-a1f1-5ea35d8b5295","order_by":6,"name":"Tore Wentzel-Larsen","email":"","orcid":"","institution":"The Norwegian Centre for Violence and Traumatic Stress Studies","correspondingAuthor":false,"prefix":"","firstName":"Tore","middleName":"","lastName":"Wentzel-Larsen","suffix":""},{"id":509986543,"identity":"282e29a0-1cc0-4e65-8959-81dd0cb16b15","order_by":7,"name":"Nadina Peters","email":"","orcid":"","institution":"The Norwegian Centre for Violence and Traumatic Stress Studies","correspondingAuthor":false,"prefix":"","firstName":"Nadina","middleName":"","lastName":"Peters","suffix":""},{"id":509986544,"identity":"d2c3e5b1-deb2-40ef-b33b-308facd8128c","order_by":8,"name":"Harald Bækkelund","email":"","orcid":"","institution":"The Norwegian Centre for Violence and Traumatic Stress Studies","correspondingAuthor":false,"prefix":"","firstName":"Harald","middleName":"","lastName":"Bækkelund","suffix":""},{"id":509986545,"identity":"bdbbe02c-e3c4-43d2-8c88-f757ee46c9c6","order_by":9,"name":"Mathilde Endsjø","email":"","orcid":"","institution":"The Norwegian Centre for Violence and Traumatic Stress Studies","correspondingAuthor":false,"prefix":"","firstName":"Mathilde","middleName":"","lastName":"Endsjø","suffix":""},{"id":509986546,"identity":"bb8cae09-b808-4104-9bb0-7c98bd180fa7","order_by":10,"name":"Ane-Marthe Solheim Skar","email":"","orcid":"","institution":"The Norwegian Centre for Violence and Traumatic Stress Studies","correspondingAuthor":false,"prefix":"","firstName":"Ane-Marthe","middleName":"Solheim","lastName":"Skar","suffix":""}],"badges":[],"createdAt":"2025-07-28 21:17:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7237246/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7237246/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91073493,"identity":"6387d43b-5f47-4c64-a0ab-b67dcfbdd063","added_by":"auto","created_at":"2025-09-11 10:58:48","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":162311,"visible":true,"origin":"","legend":"\u003cp\u003eTherapists’ intentions to use trauma assessment tools before and after the introduction of LOCI. Measure timepoints -3 to -1 are the non-LOCI periods, while measure timepoints 0 to 4 are the LOCI periods. Cohort 1 includes -1 to 4, cohort 2 includes -2 to 3, cohort 3 includes -3 to 2. The black line represents the estimated slope in the non-LOCI and LOCI periods. The large dots show the trajectories for each cohort over time.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7237246/v1/ffa5f490a5dbae0cf34e5a11.png"},{"id":91079084,"identity":"84eb3837-c067-42db-a36d-fd83076cf917","added_by":"auto","created_at":"2025-09-11 11:22:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":862208,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7237246/v1/805ed071-1e0d-4a62-b2cd-496897158c27.pdf"},{"id":91073495,"identity":"5c553361-30d3-44e4-ba1c-7de8a3bff64e","added_by":"auto","created_at":"2025-09-11 10:58:48","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":81436,"visible":true,"origin":"","legend":"","description":"","filename":"StaRIchecklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-7237246/v1/7ad58af0c94a33a4d5b9a629.docx"}],"financialInterests":"","formattedTitle":"Improving therapist adoption of evidence-based practices with the LOCI strategy: a randomized controlled trial","fulltext":[{"header":"Contributions to the literature","content":"\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eThis study contributes to the growing evidence for the effectiveness of the LOCI strategy by demonstrating its impact on therapists\u0026rsquo; adoption of EBPs in mental health clinics.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eBy examining therapists' intentions and patient recruitment as proxies for adoption, the study provides insights into the potential mechanisms driving implementation success.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThe findings emphasize the importance of early leadership engagement in the implementation process, and the need for a robust preparation phase in implementation efforts to improve implementation outcomes.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eFurther research is needed to better understand which parts of the LOCI strategy are most effective in driving long-term implementation success.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eSuccessfully integrating evidence-based practices (EBPs) into mental health care requires the identification and execution of several implementation strategies. Research shows that, without a well-defined approach, even the most effective EBPs often fail to become institutionalized in clinical practice (i.e., those who directly supervise therapists and frontline service providers, 1). In this process, leaders play a pivotal role, as they are responsible for guiding and aligning efforts across different levels of the organization (\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eLeadership and Organizational Change for Implementation (LOCI) is a multifaceted implementation strategy aimed at strengthening leaders\u0026rsquo; capacity to guide the uptake and continued use of EBPs among staff (\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). LOCI draws on two leadership theories: (i) full-range leadership emphasising general transformational leadership behaviours (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), and (ii) implementation leadership (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), which highlights proactive, knowledgeable, supportive, and perseverant leadership aimed specifically at EBP implementation. Further, it draws on the theory of organizational implementation climate (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), which emphasizes how leaders can create a context in which the use of EBPs is expected, supported, and valued. LOCI is grounded in the EPIS framework, which outlines four key phases of EBP implementation: Exploration, Preparation, Implementation, and Sustainment (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). During LOCI, the focus is primarily on inner organizational context, and the preparation and implementation phases (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eLOCI has a focus on supporting first-level leaders (i.e., those who directly supervise therapists and frontline service providers; 13), while also engaging executive leaders to ensure first-level leaders are effectively supported. This dual-level approach aims to cultivate an implementation climate that facilitates the adoption and use of EBPs (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). LOCI is grounded in the hypothesis that by strengthening the implementation climate within clinical units, leaders can increase therapists\u0026rsquo; engagement in implementation processes, thereby promoting successful implementation and, ultimately, improving patient outcomes (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe results from studies on LOCI are promising. The strategy has been tested in six randomized controlled trials (RCTs) across diverse mental health settings (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). These studies have found LOCI to be related to significantly improved implementation leadership and implementation climate (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), as well as therapists\u0026rsquo; implementation citizenship behaviors (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). LOCI has also demonstrated positive effects on therapist fidelity (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), reach (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), and patient outcomes (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Findings related to full-range leadership (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) and the maintenance of outcomes over time have been somewhat mixed (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). LOCI is a complex implementation strategy involving multiple interacting processes and mechanisms, many of which are not yet fully understood. Ongoing research aims to further explore these mechanisms (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEvidence-based trauma treatment\u003c/p\u003e\u003cp\u003ePost-traumatic stress disorder (PTSD) is a serious mental health condition that can develop after exposure to trauma, and is linked to significant impairment in daily functioning and quality of life (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). There are several EBPs for PTSD (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), yet implementing them can often be challenging (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Studies of implementation of trauma treatment in routine clinical practice are in demand (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe current study was part of an ongoing national implementation of EBPs for PTSD, funded by the Norwegian Ministry of Health and Care Services, and implemented by the Norwegian Centre for Violence and Traumatic Stress Studies (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The EBPs for trauma treatment were Trauma-Focused Cognitive Behavioral Therapy (TF-CBT; 24) in child clinics, and Cognitive Therapy for PTSD (CT-PTSD; 25) and Eye Movement Desensitization and Reprocessing (EMDR; 26) in adult clinics.\u003c/p\u003e\u003cp\u003eThe clinics were divided into three cohorts. All clinics received training in assessment tools and EBPs for trauma at the same time, while the three cohorts began participating in the LOCI strategy at different time points. As a result, each clinic had a control period (non-LOCI), followed by a LOCI period. This design led to some clinics (cohort 1) receiving training in EBPs for trauma simultaneously with the start of LOCI, while others had a delayed LOCI start (cohorts 2 and 3). Assuming that leaders provide better follow-up and support to staff when they participate in LOCI, it is reasonable to expect that therapists in cohort 1 would begin using the assessment tools and methods more quickly and to a greater extent than those in cohorts with a delayed LOCI start.\u003c/p\u003e\u003cp\u003eThe goal of this study was to investigate the effect of LOCI on therapists\u0026rsquo; adoption, defined as \u0026ldquo;the intention, initial decision, or action to try or employ an innovation or evidence-based practice\u0026rdquo; (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Adoption was measured as (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) therapists\u0026rsquo; intentions to use trauma assessment tools and the EBP for trauma treatment, and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) their action in employing these treatment methods, as indicated by recruiting patients into the study. The following hypotheses were examined:\u003c/p\u003e\u003cp\u003eH1a) Therapists\u0026rsquo; intentions to use trauma assessment tools will be significantly higher in the LOCI vs. control condition.\u003c/p\u003e\u003cp\u003eH1b) Therapists\u0026rsquo; intentions to use the EBP for trauma treatment will be significantly higher in the LOCI vs. control condition.\u003c/p\u003e\u003cp\u003eH2) Therapists in clinics that began LOCI concurrently with training in EBPs will use the EBPs significantly more than clinics with a delayed LOCI start.\u003c/p\u003e\u003cp\u003eIn the protocol of the overall study, additional hypotheses were pre-specified (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). See the appendix for analyses and results of additional hypotheses.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA stepped wedge study with three cohorts was conducted between 2018 and 2020 to examine the effect of the LOCI strategy. See study protocol for further details (\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e). The StaRI checklist was used as reporting standard (\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eParticipants\u003c/p\u003e\n\u003cp\u003eForty-three child and adult specialized mental health outpatient clinics throughout Norway implemented assessment tools and EBPs for trauma exposure and PTSD between 2018 and 2020. Forty-seven first-level leaders within the clinics participated in LOCI. The leaders were mostly female (62%), psychologists (55%), with the average age of 55 (range 41\u0026ndash;70) (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eParticipant characteristics\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eLOCI leaders (N\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eTherapists (N\u0026thinsp;=\u0026thinsp;790)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003cp\u003eWomen\u003c/p\u003e\n \u003cp\u003eMen\u003c/p\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e(61.7%)\u003c/p\u003e\n \u003cp\u003e(38.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e597\u003c/p\u003e\n \u003cp\u003e168\u003c/p\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e(78%)\u003c/p\u003e\n \u003cp\u003e(22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEducation\u003c/p\u003e\n \u003cp\u003ePsychology\u003c/p\u003e\n \u003cp\u003eMedicine\u003c/p\u003e\n \u003cp\u003eSocial worker\u003c/p\u003e\n \u003cp\u003eNursing\u003c/p\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e(55.3%)\u003c/p\u003e\n \u003cp\u003e(10.6%)\u003c/p\u003e\n \u003cp\u003e(17.0%)\u003c/p\u003e\n \u003cp\u003e(17.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e367\u003c/p\u003e\n \u003cp\u003e149\u003c/p\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e(51.3%)\u003c/p\u003e\n \u003cp\u003e(20.8%)\u003c/p\u003e\n \u003cp\u003e(7.8%)\u003c/p\u003e\n \u003cp\u003e(7.7%)\u003c/p\u003e\n \u003cp\u003e(12.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e54.7\u003c/P\u003e \u003cP\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(SD\u0026thinsp;=\u0026thinsp;7.64)\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48.9\u003c/p\u003e\n \u003cp\u003e109\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(SD\u0026thinsp;=\u0026thinsp;11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eTherapists (n\u0026thinsp;=\u0026thinsp;790) from the abovementioned clinics participated in the study. Therapists in all the clinics received training in assessment tools in the beginning of the project period, and a subgroup (n\u0026thinsp;=\u0026thinsp;301) received training in PTSD treatment methods. Most therapists were female (76%), psychologists (47%), and the average age was 49 (range 31\u0026ndash;80) (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eProcedures\u003c/p\u003e\n\u003cp\u003eAn open invitation was sent out to outpatient clinics throughout Norway, and 43 child and adult clinics volunteered to join. In child mental health clinics, the implementation had been ongoing since 2012, covering about half of the clinics in Norway at the time of the current study. In adult clinics, this was the first implementation round. The clinics in the current study had previously not participated in the EBP implementation.\u003c/p\u003e\n\u003cp\u003eAll therapists received 3 hours of training in assessment tools. For the PTSD treatment methods, clinic leaders were advised to select therapists who were motivated for training and who planned to remain in the clinic over time. A subgroup of therapists participated in a three-day course in a specific PTSD treatment method (CT-PTSD, EMDR, or TF-CBT), followed by coaching by specialists in the EBPs. The adult clinics received 10 hours of group coaching, while the child clinics received weekly group coaching (about 40 hours). Therapists in adult clinics were asked to recruit at least three patients each into the study to ensure sufficient practice. Therapists in child clinics were asked to recruit at least one patient, gradually increasing the number as they became more familiar with the method. Due to staff turnover throughout the implementation period, all clinics were offered to have more therapists trained in both 2019 and 2020 (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eTherapist training and patient recruitment\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCohort 1\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCohort 2\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCohort 3\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrained in screening tools\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e790\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrained in treatment methods\u003c/p\u003e\n \u003cp\u003eTF-CBT\u003c/p\u003e\n \u003cp\u003eEMDR\u003c/p\u003e\n \u003cp\u003eCT-PTSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e104 (35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e90 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e107 (35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e301\u003c/p\u003e\n \u003cp\u003e116 (39%)\u003c/p\u003e\n \u003cp\u003e97 (32%)\u003c/p\u003e\n \u003cp\u003e87 (29%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo. of recruited patients\u003c/p\u003e\n \u003cp\u003eTF-CBT\u003c/p\u003e\n \u003cp\u003eEMDR\u003c/p\u003e\n \u003cp\u003eCT-PTSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e191 (40%)\u003c/p\u003e\n \u003cp\u003eM\u0026thinsp;=\u0026thinsp;1.84 (0\u0026ndash;6)\u003c/p\u003e\n \u003cp\u003e103 (54%)\u003c/p\u003e\n \u003cp\u003e56 (29%)\u003c/p\u003e\n \u003cp\u003e32 (17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e152 (31%)\u003c/p\u003e\n \u003cp\u003eM\u0026thinsp;=\u0026thinsp;1.71(0\u0026ndash;7)\u003c/p\u003e\n \u003cp\u003e61 (40%)\u003c/p\u003e\n \u003cp\u003e54 (36%)\u003c/p\u003e\n \u003cp\u003e37 (24%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e141 (29%)\u003c/p\u003e\n \u003cp\u003eM\u0026thinsp;=\u0026thinsp;1.32 (0\u0026ndash;12)\u003c/p\u003e\n \u003cp\u003e52 (37%)\u003c/p\u003e\n \u003cp\u003e42 (30%)\u003c/p\u003e\n \u003cp\u003e47 (33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e484\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e216 (45%)\u003c/p\u003e\n \u003cp\u003e152 (31%)\u003c/p\u003e\n \u003cp\u003e116 (24%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTherapists with no recruitments\u003c/p\u003e\n \u003cp\u003eTF-CBT\u003c/p\u003e\n \u003cp\u003eEMDR\u003c/p\u003e\n \u003cp\u003eCT-PTSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31 (29%)\u003c/p\u003e\n \u003cp\u003e15 (42%)\u003c/p\u003e\n \u003cp\u003e6 (16%)\u003c/p\u003e\n \u003cp\u003e10 (29%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26 (24%)\u003c/p\u003e\n \u003cp\u003e7 (19%)\u003c/p\u003e\n \u003cp\u003e12 (32%)\u003c/p\u003e\n \u003cp\u003e7 (21%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50 (47%)\u003c/p\u003e\n \u003cp\u003e14 (39%)\u003c/p\u003e\n \u003cp\u003e19 (52%)\u003c/p\u003e\n \u003cp\u003e17 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e107\u003c/p\u003e\n \u003cp\u003e36 (33.5%)\u003c/p\u003e\n \u003cp\u003e37 (34.5%)\u003c/p\u003e\n \u003cp\u003e34 (32%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e2018\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e2019\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e2020\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTime trained\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e203\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e301\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe clinics were randomized into one of three cohorts representing the timepoint when leaders would begin their engagement in the LOCI strategy. The first cohort began at baseline, concurrently with the EBP training (16 leaders). The second cohort began 4 months after the EBP training (14 leaders), and the third cohort 8 months after the EBP training (17 leaders). Participation in LOCI was one year for all three cohorts (see Supplementary Material for participant flow).\u003c/p\u003e\n\u003cp\u003eThe LOCI training consisted of five days of training (2 days of training when beginning LOCI, and one day of training every quarter thereafter). During these trainings, the first-level leaders (hereafter called LOCI leaders) were introduced to general and strategic leadership principles and implementation climate. They also received results from 360\u0026deg; assessments of their leadership and the clinic\u0026rsquo;s climate. Based on these results, they developed individualized leadership development plans. The leaders had weekly coaching calls by phone with a LOCI facilitator to discuss their progress on the leadership plans. Once a month, this individual coaching call was replaced with group coaching calls for all LOCI leaders within the cohort.\u003c/p\u003e\n\u003cp\u003eTo promote leadership alignment, executive leaders were actively involved in the LOCI process. After each LOCI training session, Organizational Strategy Meetings (OSMs) were held, involving LOCI leaders, executive leaders, and other key staff members. These meetings were organized by health trust: when multiple clinics from the same trust participated, joint OSMs were conducted with one executive leader, several LOCI leaders, and relevant central staff. When only one clinic from a trust participated, the OSM included one executive leader, one LOCI leader, and other central staff members. During these meetings, aggregated data on the implementation climate were shared, and climate development plans were co-created to outline the steps the organization would take to support EBP implementation. These plans were tailored over time to respond to emerging challenges, organizational needs, and new opportunities. To ensure continued progress and follow-up, executive leaders also participated in monthly 30-minute individual phone calls, where they discussed and monitored the advancement of their climate development plans. Leaders and therapists completed surveys at baseline, and after 4, 8, 12, 16, and 20 months (T0-T5).\u003c/p\u003e\n\u003cp\u003eMeasures\u003c/p\u003e\n\u003cp\u003eThe Measure of Innovation-Specific Implementation Intention (MISII) was used to measure therapists\u0026rsquo; intentions to implement the EBPs for PTSD (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e). The MISII consists of three items that each capture an aspect of intention: plans, desire, and scope. The MISII was adapted for this project to measure therapists\u0026rsquo; intentions to implement a) the trauma assessment tools \u003cem\u003e(intent to assess)\u003c/em\u003e, and b) the specific EBP \u003cem\u003e(intent to treat)\u003c/em\u003e. The items were rated on a 5-point scale from 0 (\u0026ldquo;not at all\u0026rdquo;) to 4 (\u0026ldquo;a very great extent\u0026rdquo;). The Cronbach\u0026apos;s alpha ranged from 0.95 to 0.96 for the different time points (T0-T5), indicating excellent internal consistency.\u003c/p\u003e\n\u003cp\u003eTherapists\u0026rsquo; use of the trauma EBP was assessed as indicated by their recruitment of patients for treatment. Specifically, recruitment was assessed as a) whether the trained therapists recruited any patients into the project, b) how many they recruited during the project period, and c) the length of time to recruit their first patient following the trauma treatment training.\u003c/p\u003e\n\u003cp\u003eAnalyses\u003c/p\u003e\n\u003cp\u003eTo examine LOCI\u0026rsquo;s effect on therapists\u0026rsquo; intentions, linear mixed-effects models were performed. These models account for data dependency, accommodate irregular measurement intervals (\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e), and can handle missing data (\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e). The models included fixed effects representing change before and during the LOCI intervention, and random effects to account for variability between clinics and between therapists in both intercept and slope. The random structure was simplified when necessary to ensure model stability (\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e). In supplementary analyses, categorical variables were added to examine differences between cohorts and clinic types (child versus adult).\u003c/p\u003e\n\u003cp\u003eAn immediate increase in the outcome at the start of LOCI, reflected by an initial shift in the intercept, would be interpreted as the immediate effect of LOCI. A positive value would indicate improvement. A steeper upward slope following LOCI would suggest that the intervention\u0026apos;s effect continued to grow over time after the commencement of LOCI.\u003c/p\u003e\n\u003cp\u003eThere were 2.3% missing data for the MISII assessment tools, and 19% for the MISII treatment methods. Missing data were excluded listwise at the item level: if two out of three items for a given measure were missing, that specific measure was excluded from the analysis for that case. To assess the internal validity of the MISII, Cronbach\u0026rsquo;s alpha was calculated.\u003c/p\u003e\n\u003cp\u003eTo examine differences in recruitment status (yes/no) across the three cohorts, a logistic regression was performed. Differences in the number of patients recruited were assessed using negative binominal regression. To compare cohorts 2 and 3 directly, the reference category was changed and the regression models re-estimated. Time from training to first patient recruitment was analyzed with Kaplan\u0026ndash;Meier estimators. Robust standard errors and 95% confidence intervals were calculated for the logistic regression, negative binomial regression, and Kaplan\u0026ndash;Meier survival analyses to account for non-independence and clustering (i.e., therapists within clinics).\u003c/p\u003e\n\u003cp\u003eAll analyses were performed in R (\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e). The nlme package (\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e) was used for linear mixed-effects modeling. Internal consistency analyses used the psych package (\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e). Data were subsetted by measurement time points (T0-T5) using dplyr (\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e). Logistic and negative binomial regressions were performed using glm and glm.nb from the MASS package (\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e). Time-to-event analyses were conducted using the survfit function (\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e) and plotted with ggsurvplot from the survminer package (\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIntentions to use trauma assessment tools\u003c/p\u003e\n\u003cp\u003eWhen LOCI was introduced, there was a significant increase in therapists\u0026rsquo; intentions to use assessment tools compared to the control period (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). While there was no significant trend in therapists\u0026rsquo; intentions before LOCI were introduced, there was a small, but significant increase in the slope in the LOCI period.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eThe effect of LOCI based on mixed effects analyses\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003eEffect\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eEstimate\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eLL\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eUP\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eIntentions to use trauma assessment tools\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eValue when LOCI starts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon-LOCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLOCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDifference LOCI non-LOCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eSlope\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon-LOCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.200\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLOCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDifference LOCI non-LOCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.542\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntentions to use treatment methods\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eValue when LOCI starts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon-LOCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLOCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDifference LOCI non-LOCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.177\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eSlope\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon-LOCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.069\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLOCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.177\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDifference LOCI non-LOCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.203\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThere was a statistically significant difference in LOCI\u0026apos;s effect between adult and child clinics (three-way interaction: coefficient = -0.295, p\u0026thinsp;\u003cem\u003e\u0026lt;\u003c/em\u003e\u0026thinsp;.001). Adult clinics demonstrated a small negative, but not significant slope prior to LOCI (coefficient = -0.04, p\u0026thinsp;=\u0026thinsp;0.432). At the introduction of LOCI, there was a significant increase in therapists\u0026rsquo; intentions (coefficient\u0026thinsp;=\u0026thinsp;0.46, \u003cem\u003ep\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;.001), and the post-LOCI slope was significantly positive (coefficient\u0026thinsp;=\u0026thinsp;0.08, p\u0026thinsp;\u003cem\u003e\u0026lt;\u003c/em\u003e\u0026thinsp;.001). In contrast, child clinics demonstrated a significant positive slope prior to LOCI (coefficient\u0026thinsp;=\u0026thinsp;0.21, p\u0026thinsp;\u003cem\u003e\u0026lt;\u003c/em\u003e\u0026thinsp;.001). When LOCI was introduced, child clinics, like adult clinics, had a significant increase in therapists\u0026rsquo; intentions (coefficient\u0026thinsp;=\u0026thinsp;0.29, \u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;.004). Following LOCI introduction, it continued on a positive slope (coefficient\u0026thinsp;=\u0026thinsp;0.06, p\u0026thinsp;=\u0026thinsp;0.017), but significantly declined in magnitude (coefficient = -0.15, p\u0026thinsp;=\u0026thinsp;0.015).\u003c/p\u003e\n\u003cp\u003eIntentions to use EBPs\u003c/p\u003e\n\u003cp\u003eRegarding therapists\u0026rsquo; intentions to implement the EBP, there was no significant difference between LOCI and non-LOCI in either value at the transition or rate of change over time. Therapists\u0026rsquo; intentions were high at baseline, as reflected in the elevated initial scores across both groups (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e and Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e), and stayed high over time.\u003c/p\u003e\n\u003cp\u003eUse of EBPs\u003c/p\u003e\n\u003cp\u003eThe number of recruited patients per therapist after receiving EBP training is shown in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. A negative binominal regression examining recruitment across cohorts showed that therapists in cohort 3 recruited significantly fewer patients than those in cohort 1 (IRR\u0026thinsp;=\u0026thinsp;0.72, 95% CI [0.52, 0.99], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.043). There was no significant difference between cohort 2 and 1 (IRR\u0026thinsp;=\u0026thinsp;0.92, 95% CI [0.71, 1.19], \u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.529), nor between cohort 2 and 3 (IRR\u0026thinsp;=\u0026thinsp;0.78, 95% CI [0.56, 1.08], \u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.139).\u003c/p\u003e\n\u003cp\u003eA logistic regression showed that significantly fewer therapists in cohort 3 recruited patients than those in cohort 1 (OR\u0026thinsp;=\u0026thinsp;0.48, 95% CI [0.27, 0.85], \u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.012) and 2 (OR\u0026thinsp;=\u0026thinsp;0.49, 95% CI [0.27, 0.88], \u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.017). There was no sigificant difference between cohorts 1 and 2 (OR\u0026thinsp;=\u0026thinsp;0.99, 95% CI [0.54, 1.84], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.977).\u003c/p\u003e\n\u003cp\u003eKaplan-Meier survival analysis using Cox proportional hazards regression showed no significant differences between cohorts regarding time from trauma treatment training to first patient recruitment (Wald test: \u0026chi;\u0026sup2;(\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;0.18, p\u0026thinsp;=\u0026thinsp;0.90). HR for cohort 2 vs. 1: 0.94, 95% CI [0.62, 1.42]; HR for cohort 3 vs. 1: 1.03, 95% CI [0.70, 1.51].\u003c/p\u003e\n\u003cp\u003eAdditional analyses of secondary hypotheses are presented in the Appendix. Briefly, no significant effects of LOCI were found on therapists\u0026rsquo; job demands or implementation citizenship behavior (ICB), although ICB increased during the control period.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrated that leaders\u0026rsquo; participation in the LOCI strategy had a significant impact on therapists\u0026rsquo; adoption. There was a significant increase in adoption when LOCI was introduced, and we assume that this effect was driven by leaders applying leadership and climate-embedding strategies as part of the LOCI strategy (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). These strategies may have enhanced therapists\u0026rsquo; intentions to use trauma assessment tools. Furthermore, clinics where leaders began their participation in LOCI concurrently with therapists\u0026rsquo; training in the EBPs (cohort 1) showed higher rates of patient recruitment compared to clinics where leaders began their participation in LOCI four or eight months after therapists received their training. These findings suggest that early leadership engagement may support therapists in adopting the methods, possibly through demonstrating commitment to the implementation and sustainment of EBPs (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). In contrast, delayed leadership involvement following the start of implementation may lead to poorer implementation outcomes.\u003c/p\u003e\u003cp\u003eThere was a significant difference in the pre-LOCI slope regarding intentions over time between child and adult clinics. Following EBP training but prior to engagement in LOCI, therapists in child clinics demonstrated a significant rate of increase in their intentions to use trauma assessment tools, whereas the levels of intentions among therapists in adult clinics was flat. After the start of LOCI, the pattern was similar across child and adult clinics; there was a significant jump in the intentions at the start of LOCI and a similar significant, positive slope after LOCI. Thus, the primary difference between the child and adult clinics was how therapist intentions changed over time after the initial EBP training. The implementation of trauma assessment tools and treatment methods has been ongoing in Norwegian child clinics since 2012. This longstanding practice may have influenced the participating clinics, as it has become increasingly common to assess for trauma and PTSD in specialized child mental health clinics. Although the participating clinics had not previously received training in systematic assessment, several of them already used the assessment forms. Consequently, the training may have served more as a reminder in child clinics for practices partly established. In contrast, in adult specialized mental health clinics, this represented the first implementation round, where assessing for trauma and PTSD had not been previously emphasized. Regardless, the results demonstrated a significant increase when leaders participated in LOCI, highlighting the importance of leaders taking the lead and paving the way for therapists\u0026rsquo; intentions.\u003c/p\u003e\u003cp\u003eIt is important to note that intentions do not equate to actual usage, but rather are considered an assumed prerequisite for adoption (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). Similarly, we do not know if patient recruitment into the research study reflected actual usage within the services. However, this could not be measured as Norwegian healthcare services lack systems for recording assessment and method usage. Nonetheless, investigating therapists\u0026rsquo; intentions and their recruitment into the research study serves as a useful proxy and provides insight into potential adoption and utilization of new tools and methods.\u003c/p\u003e\u003cp\u003eThere were no statistically significant findings related to therapists\u0026rsquo; intentions to use the treatment methods. However, statistical power was low, meaning that small true differences may have gone undetected. Furthermore, no significant differences were found between cohorts in the time from training to first patient recruitment. Nevertheless, the sample consisted of a self-selected group of therapists with a high level of motivation and strong intentions to learn and use trauma-focused treatments from the outset. It might be that leaders\u0026rsquo; participation in LOCI may be less impactful for this smaller group of motivated therapists during the initial learning phase. At the same time, in the long run, the absence of leadership support during training may hinder sustained implementation if therapists do not begin using the methods in practice, as suggested by the recruitment data. This, in turn, could impede the institutionalization of the newly gained knowledge.\u003c/p\u003e\u003cp\u003eThe findings of this study add to the growing body of evidence supporting the effectiveness of LOCI. However, there were also null findings regarding LOCI\u0026rsquo;s impact on job demands and implementation citizenship behavior (see Appendix), indicating mixed results compared to previous studies (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). LOCI is a complex, multi-component strategy, and further research is needed to identify which elements drive its effects.\u003c/p\u003e\u003cp\u003eIn this study, LOCI was initiated concurrently with, or shortly after, training in trauma assessment tools and treatment methods. However, more recent studies highlight the importance of a robust preparation phase to ensure readiness for implementation (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). It may therefore be beneficial to initiate LOCI earlier to allow more time for preparatory activities. It should also be noted that all participating clinics joined voluntarily, which involved mandatory participation in LOCI. This may limit the generalizability of the findings to clinics where participation is less voluntary.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe study underscores the importance of early leadership engagement in the LOCI strategy, which significantly enhanced therapists' intentions to use trauma assessment tools and increased patient recruitment rates. Clinics with concurrent leadership and therapist EBP training showed better outcomes, illustrating the need for early leadership engagement in facilitating method adoption. Although intentions and recruitment are not equivalent to actual use, the findings highlight potential adoption patterns. Further research is needed to identify key elements of LOCI that support sustained implementation.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLOCI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLeadership and Organizational Change for Implementation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEBP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEvidence-Based Practices\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePTSD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePost-Traumatic Stress Disorder\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003eThe study was approved by the Norwegian Centre for Violence and Traumatic Stress Studies (NKVTS), which is responsible for data processing. A data protection impact assessment was reviewed and assessed by SIKT \u0026ndash; the Norwegian Agency for Shared Services in Education and Research (NSD 60036/3/LH, NSD 60059/3/OOS). The study is registered in ClinicalTrials NCT03719651, 25th of October 2018. Informed consent was obtained from all relevant participants.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThe implementation project was funded by the Norwegian Ministry of Health and Care Services. The funders had no role in planning, designing, and analyzing the results.\u003c/p\u003e\u003ch2\u003eAuthors\u0026rsquo; contributions\u003c/h2\u003e\u003cp\u003eAMSS and KME were responsible for all parts of the study. KME, RHB, NB, and TWL participated in the preparation of data files and the execution of analyses. NP, HB, and ME helped with planning and coordinating the study and data collection. MGE, MS, and GAA contributed to the conception and design of the study. KME had primary responsibility for writing the manuscript. All authors contributed to the writing of the manuscript and approved the final version.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eWe gratefully acknowledge the participating leaders, therapists, supervisors, and other staff for collaborating with us and providing data for this study.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\u003cp\u003eThe datasets will be available from the corresponding author on reasonable request. LOCI training materials are the property of Behavioral Change Consulting.\u003c/p\u003e\u003cp\u003eCompeting interests\u003c/p\u003e\u003cp\u003eGAA is co-Editor-in-Chief of \u003cem\u003eImplementation Science\u003c/em\u003e and on the editorial board of \u003cem\u003eImplementation Science Communications\u003c/em\u003e. All decisions about this paper were made other editors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFontaine G, Vinette B, Weight C, Maheu-Cadotte M-A, Lavall\u0026eacute;e A, Desch\u0026ecirc;nes M-F, et al. Effects of implementation strategies on nursing practice and patient outcomes: a comprehensive systematic review and meta-analysis. Implement Sci. 2024;19(1):68.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMeza RD, Triplett NS, Woodard GS, Martin P, Khairuzzaman AN, Jamora G, et al. The relationship between first-level leadership and inner-context and implementation outcomes in behavioral health: a scoping review. Implement Sci. 2021;16(1):1\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEhrhart MG, Aarons GA, Alignment. Impact on implementation processes and outcomes. Implementation Science: Routledge; 2022. pp. 171\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAarons GA, Farahnak LR, Ehrhart MG, Sklar M. Aligning Leadership Across Systems and Organizations to Develop Strategic Climate to for Evidence-Based Practice Implementation. Annu Rev Public Health. 2014;35:255\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAarons G, Sklar M, Ehrhart MG, Roesch S, Moullin JC, Carandang K. Randomized trial of the leadership and organizational change for implementation (LOCI) strategy in substance use treatment clinics. J Subst Use Addict Treat. 2024;165:209437.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAarons GA, Ehrhart MG, Moullin JC, Torres EM, Green AE. Testing the leadership and organizational change for implementation (LOCI) intervention in substance abuse treatment: a cluster randomized trial study protocol. Implement Sci. 2017;12(1):29.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAarons GA, Ehrhart MG, Farahnak LR, Hurlburt MS. Leadership and organizational change for implementation (LOCI): a randomized mixed method pilot study of a leadership and organization development intervention for evidence-based practice implementation. Implement Sci. 2015;10:11.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBass BM. From transactional to transformational leadership: Learning to share the vision. Organ Dyn. 1990;18(3):19\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAarons GA, Ehrhart MG, Farahnak LR. The Implementation Leadership Scale (ILS): development of a brief measure of unit level implementation leadership. Implement Sci. 2014;9(1):45.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEhrhart M, Aarons GA, Farahnak LR. Assessing the organizational context for EBP implementation: the development and validity testing of the Implementation Climate Scale (ICS). Implement science: IS. 2014;9:157.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMoullin JC, Dickson KS, Stadnick NA, Rabin B, Aarons GAJIS. Systematic review of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. Implement Sci. 2019;14(1):1.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAarons GA, Hurlburt M, Horwitz SM. Advancing a conceptual model of evidence-based practice implementation in public service sectors. Adm Policy Mental Health Mental Health Serv Res. 2011;38(1):4\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePriestland A, Hanig R. Developing first-level leaders. Harvard Business Rev. 2005;83(6):112\u0026ndash;20. 50.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWilliams NJ, Marcus SC, Ehrhart MG, Sklar M, Esp SM, Carandang K, et al. Randomized Trial of an organizational implementation strategy to improve measurement-based Care Fidelity and Youth outcomes in Community Mental Health. Journal of the American Academy of Child \u0026amp; Adolescent Psychiatry; 2023.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBrookman-Frazee L, Lau AS, Roesch SC, Jobin A, Chlebowski C, Mello M, et al. Effectiveness of Multilevel Implementation Strategies for Autism Interventions: Outcomes of Two Linked Implementation Trials. Journal of the American Academy of Child \u0026amp; Adolescent Psychiatry; 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEgeland K, Skar A-MS, Endsj\u0026oslash; M, Laukvik EH, B\u0026aelig;kkelund H, Babaii A, et al. Testing the leadership and organizational change for implementation (LOCI) intervention in Norwegian mental health clinics: a stepped-wedge cluster randomized design study protocol. Implement Sci. 2019;14(1):28.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSkar A-MS, Braathu N, Peters N, B\u0026aelig;kkelund H, Endsj\u0026oslash; M, Babaii A et al. A stepped-wedge randomized trial investigating the effect of the Leadership and Organizational Change for Implementation (LOCI) intervention on implementation and transformational leadership, and implementation climate. BMC Health Serv Res 2022;22(298).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWilliams NJ, Ehrhart MG, Aarons GA, Esp S, Sklar M, Carandang K, et al. Improving measurement-based care implementation in youth mental health through organizational leadership and climate: a mechanistic analysis within a randomized trial. Implement Sci. 2024;19(1):29.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWilliams NJ, Aarons GA, Ehrhart MG, Esp S, Vega N, Sklar M et al. Effects of an Organizational Implementation Strategy on Sustainment of Measurement-Based Care in Community Mental Health. Psychiatric services. 2025:appi. ps. 20240302.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLocke J, Corbin CM, Collins VK, Ehrhart MG, Goosey R, Hatch K, et al. Helping Educational Leaders Mobilize Evidence (HELM): The iterative redesign of the Leadership and Organizational Change for Implementation (LOCI) intervention for use in schools. Implement Res Pract. 2024;5:26334895241242523.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOlff M, Hein I, Amstadter AB, Armour C, Skogbrott Birkeland M, Bui E, et al. The impact of trauma and how to intervene: a narrative review of psychotraumatology over the past 15 years. Eur J Psychotraumatology. 2025;16(1):2458406.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNICE. Post-traumatic stress disorder. NICE guideline. 2018.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePfeiffer E, Unterhitzenberger J, Enderby P, Juusola A, Kostova Z, Lindauer RJ, et al. The dissemination and implementation of trauma-focused cognitive behavioural therapy for children and adolescents in seven European countries. BMC Health Serv Res. 2024;24(1):1202.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCohen JA, Mannarino AP, Deblinger E. Treating trauma and traumatic grief in children and adolescents. New York, NY: Guildford; 2006.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEhlers A, Clark DM. A cognitive model of posttraumatic stress disorder. Behav Res Ther. 2000;38(4):319\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShapiro F, Laliotis D. EMDR Therapy for Trauma-Related Disorders. In: Schnyder U, Cloitre M, editors. Evidence Based Treatments for Trauma-Related Psychological Disorders: A Practical Guide for Clinicians. Cham: Springer International Publishing; 2015. pp. 205\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eProctor EK, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Mental Health Mental Health Serv Res. 2011;38(2):65\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePinnock H, Barwick M, Carpenter CR, Eldridge S, Grandes G, Griffiths CJ, et al. Standards for Reporting Implementation Studies (StaRI) Statement. BMJ. 2017;356:i6795.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMoullin JC, Ehrhart MG, Aarons GA. Development and testing of the Measure of Innovation-Specific Implementation Intentions (MISII) using Rasch measurement theory. Implement Sci. 2018;13(1):89.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGibbons RD, Hedeker D, DuToit S. Advances in analysis of longitudinal data. Ann Rev Clin Psychol. 2010;6:79\u0026ndash;107.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMatuschek H, Kliegl R, Vasishth S, Baayen H, Bates D. Balancing Type I error and power in linear mixed models. J Mem Lang. 2017;94:305\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePinheiro J, Bates D. Mixed-effects models in S and S-PLUS. Springer Science \u0026amp; Business Media; 2006.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eR Core Team. R: A language and environment for statistical computing. R Foundation for Statistical Computing. editor. Vienna, Austria: R Foundation for Statistical Computing; 2021.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePinheiro JC. nlme: linear and nonlinear mixed effects models. R package version 3.1\u0026ndash;98. In: Pinheiro JC, editor. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://cran.r-project.org/web/packages/nlme/index.html\u003c/span\u003e\u003cspan address=\"https://cran.r-project.org/web/packages/nlme/index.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e2011.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRevelle W. psych: Procedures for Personality and Psychological Research. 1.5.4 ed. Evanston. Illinois, USA: Northwestern University; 2015.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWickham H, Fran\u0026ccedil;ois R, Henry L, M\u0026uuml;ller K, Vaughan D. dplyr: A Grammar of Data Manipulation. R package version 1.1.4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://dplyr.tidyverse.org\u003c/span\u003e\u003cspan address=\"https://dplyr.tidyverse.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVenables WN, Ripley BD. Modern Applied Statistics with S. 4th ed. Springer; 2002.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eR Development Core Team. survival: Survival Analysis. R package version 3.5-5. 2023.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKassambara A, Kosinski M, Biecek P, survminer. Drawing Survival Curves using \\'ggplot2\\'. R package version 0.5. 2024.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchein EH. Organizational culture and leadership. San Fransisco, CA: Wiley; 2010.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eStetler CB, Ritchie JA, Rycroft-Malone J, Charns MP. Leadership for evidence‐based practice: strategic and functional behaviors for institutionalizing EBP. Worldviews Evidence‐Based Nurs. 2014;11(4):219\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDamschroder LJ, Reardon CM, Opra Widerquist MA, Lowery J. Conceptualizing outcomes for use with the Consolidated Framework for Implementation Research (CFIR): the CFIR Outcomes Addendum. Implement Sci. 2022;17(1):7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWilliams NJ. Assessing mental health clinicians\u0026rsquo; intentions to adopt evidence-based treatments: reliability and validity testing of the evidence-based treatment intentions scale. Implement Sci. 2016;11(1):60.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlley ZM, Chapman JE, Schaper H, Saldana L. The relative value of Pre-Implementation stages for successful implementation of evidence-informed programs. Implement Sci. 2023;18(1):30.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"implementation-science","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"imps","sideBox":"Learn more about [Implementation Science](http://implementationscience.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/IMPS/default.aspx","title":"Implementation Science","twitterHandle":"@ImplementSci","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"adoption, implementation leadership, implementation strategy, LOCI, posttraumatic stress disorder","lastPublishedDoi":"10.21203/rs.3.rs-7237246/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7237246/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: This study tested the effect of the Leadership and Organizational Change for Implementation (LOCI) strategy, aimed at helping leaders support and promote organizational change for implementation of evidence-based practice (EBP). The study aimed to evaluate the effects of LOCI on adoption, measured as (1) mental health therapists’ intentions to use assessment tools and EBPs for trauma, and (2) actual use of the EBPs, as indicated by patient recruitment for the EBP service.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A stepped wedge cluster randomized design with three cohorts was conducted in Norwegian child and adult specialized mental health clinics implementing trauma assessment tools and one of three EBPs for trauma treatment. Therapists (n=790) received training in assessment tools, and a subgroup (n=301) received training in one of three EBPs. At the same time, a first cohort of leaders (n=16) began the one-year LOCI strategy, with cohorts 2 (n=14) and 3 (n=17) starting four and eight months later, respectively. Surveys included measures of intentions to implement trauma assessment tools and the EBP for trauma treatment, and were conducted at baseline, 4, 8, 12, 16, and 20 months. Actual use was measured by therapists’ recruitment of patients for treatment. To examine LOCI’s effect on therapists’ intentions, linear mixed-effects models were performed. To examine differences in recruitment status across the three cohorts, a logistic regression and a negative binominal regression were performed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Across the three cohorts, therapists’ intentions to use trauma assessment tools increased significantly when the LOCI strategy was introduced. Intentions to use the trauma treatment methods were high from the start, and did not increase significantly when LOCI was introduced. Patient recruitment differed among cohorts. Therapists in cohort 3 recruited significantly fewer patients than those in cohort 1. Additionally, significantly fewer therapists in cohort 3 had recruited at least one patient than those in cohort 1 and 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: LOCI effectively increased therapists' EBP adoption, emphasizing the importance of early leadership engagement in enhancing uptake of new EBPs. Findings suggest that delayed leadership engagement after EBP training may hinder implementation. Timely support from leaders is crucial for therapists to implement new practices.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration:\u003c/strong\u003eClinicalTrials NCT03719651, 5th of July 2018. 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