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8 Developing and Sustaining a Learning System to Support Military Family Readiness and Well-Being
Pages 273-324

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From page 273...
... . We also examine opportunities for utilizing advancements in big data analytics and mobile platforms/wearables to enhance the MFRS.
From page 274...
... . A growing body of research has documented similar influences in military families (see Chapters 5 and 6 for a review)
From page 275...
... . Research trials of such programs may also include testing of adaptations of EBPs using individualized delivery platforms, such as internet-based or mobile-application delivery tools. 
From page 276...
... This well-documented "translational gap" from research to practice poses multiple obstacles within civilian settings, and those problems are only amplified within the DoD context, given its highly diverse population (e.g., diverse by service branch, geography, and family constellation) and the highly dynamic context of military service and military family readiness related to wartime service demands, emerging types of warfare, and changes in policies (e.g., Beardslee et al., 2011, 2013; Dworkin et al., 2008)
From page 277...
... note: There is ample documentation of mismatches among interventions, the populations they target, the communities they serve, and the service sys tems where they are delivered. The documented mismatch can result from multiple factors where the context and target population differ from the original intervention testing, including age, race, ethnicity, culture, orga nization, language, accessibility, dosage, intensity of intervention, staffing, and resource limitations.
From page 278...
... s with many relatively new scientific fields, implementation science is just one of many terms used to generally convey research focused on bridging the research-to-practice gap. Related terms and processes include dissemination, knowledge translation, diffusion, research-to-practice, discovery-to-delivery, quality improvement research, and improvement science, among others.5 Dissemination and implementation science includes all the components of this process, including the decision to adopt an intervention within a system, its development and engagement on it with stakeholders, workforce 5  The authors cite work by McKibbon et al.
From page 279...
... , and administrative management. It can inform behavioral health and social service research and service delivery to guide the processes that can bridge the research-to-practice gap and lead to greater integration of EBP and evidence-informed practice (EIP)
From page 280...
... ONGOING ADAPTATION FRAMEWORK FOR A COMPLEX MILITARY FAMILY READINESS SYSTEM Applying both the population-level and ecological models presented earlier in this report to examine military family well-being, the committee extends these to inform the continuum of military family readiness services that would be responsive to the complex and emergent needs of a complex adaptive system (see Figure 7-1 in Chapter 7)
From page 281...
... It also conveys the role of continuous monitoring in supporting the integration and sustainability of interventions as they are adapted to the ever-changing context in which they are delivered, including changes occurring in the delivery setting, the target population, the evidence base, the political context, and other key variables that are known to occur over time (Chambers et al., 2013)
From page 282...
... proposed a framework and coding system for modifications and adaptations to EBP based on a systematic review of the literature. Their intervention adaptations were classified into five broad categories and associated subcategories (Stirman et al., 2013, Figure 2, p.
From page 283...
... . Using the Adaptome approach, and supplementing this with existing literature on the science of intervention adaptation, in the following pages we present several examples of ways in which existing EBPs can be adapted, monitored, and refined over time to meet the needs of military family resilience and well-being in the military health care and community settings in which they could be delivered.
From page 284...
... They could include use of instructional examples that are more relevant to the target population, such as having pictures included in intervention materials, or having names and locations of delivery sites, or localizing the available resources. To better achieve such matches, rapid-cycle usability testing6 can be done on an 6  A model of using small tests to accelerate improvement.
From page 285...
... This approach could be leveraged over time to make improvements to intervention materials delivered within the same setting, or in subsequent iterations of the intervention as it is delivered to members of the target population in different geographic regions, having different literacy rates, or within different age ranges. Delivery Adaptations This type of adaptation focuses on changes that may be needed concerning how the intervention is delivered in terms of number of sessions (e.g., 5 vs.
From page 286...
... Cultural adaptations go beyond minor changes to the names, locations, and lists of relevant resources and services. They include changes to culture-specific nomenclature used in intervention materials, which may vary by geographic region or by subpopulation, for example by urban versus rural; in the use of "y'all" versus "you all" for Southern versus non-Southern target populations; or by African American young adults versus African American middle-aged adults.
From page 287...
... . This information could be used to help guide the selection of interventions for their target populations, such as existing interventions developed for civilian populations found within the Clearinghouse for Military Family Readiness7 (Perkins et al., 2015)
From page 288...
... For example, datasets in the Defense Manpower Data Center could be triangulated to identify target populations in greatest need of additional or more intense mental health treatments, based on prevalence rates of posttraumatic stress disorder, suicidality, or depression. Additional civilian datasets can be augmented with military identifiers to track military child and family needs, align policy, and monitor interventions.9 9  For more information, see https://www.militarychild.org/resources/policies-initiatives?
From page 289...
... As an example highly relevant to the complex adaptive MFRS, this system-level intervention demonstrates the potential of an alternative rigorous method to advance the field beyond conventional tests of smaller-scale programs and interventions that are not sustainable and do not generalize to scaled-up im plementation efforts in complex community settings such as public schools. The approach suggests that large-scale impact can be achieved through a monitoring framework that embraces the huge variations in local circumstances, needs, and preferences while providing an empirical basis that helps to select the existing evidence-based programs most appropriate for each local context, helps to imple ment them, and helps to evaluate their impact in the local context.
From page 290...
... As noted in Chapter 7 and as outlined in the measurement section, qualitative and quantitative approaches can be used to assess implementation outcomes. Dissemination and implementation science has supported the delivery of a tiered-population approach to promotion and prevention, consistent with the Spectrum of Coordinated Support presented in Chapter 7 (refer to Figure 7-1)
From page 291...
... . Multiple factors are linked to increased sustainability; however, for the complex adaptive system infrastructure two factors seem essential: a continuous quality improvement process and ongoing, proactive technical assistance (e.g., implementation coaching)
From page 292...
... . Supporting a Learning Infrastructure A useful model for achieving greater accountability, agility, and family/ client-centered outcomes in the complex adaptive MFRS may be drawn from the "learning health system" framework, defined here as a learning infrastructure.
From page 293...
... . Big Data Within a learning infrastructure, big data and predictive analytics have significant potential to promote military family readiness and well-being by 10  See https://nam.edu/programs/value-science-driven-health-care/learning-health-system-series.
From page 294...
... account for socioeconomic and sociodemographic differences; accounting for such differences is similarly important in military communities and for military providers, considering the diversity of trainees, active-duty members, and their families. Ultimately, the big data that are generated by military service members, their families, and networks form the backbone of the learning infrastructure within an optimized complex adaptive system for military families.
From page 295...
... This could provide important evidence regarding the implementation, service, and participant outcomes. The goal of CQI is to provide actionable data that enable the complex adaptive system to address various outcomes, such as implementation, service, and customer outcomes, through specific identifiable adaptations or innovations (Procter, 2011)
From page 296...
... is one example of an existing DoD military family readiness program with the potential to apply an adaptive approach to implementation consistent with a dynamic sustainability framework. Designed to strengthen family resilience, the program was adapted from the developers' evidence-based practices, which had been found through randomized control trials over longitudinal follow-up to improve parenting, family functioning, and youth and parent outcomes.
From page 297...
... To be successfully utilized for military family readiness and well-being, big data must be integrated into four major categories while also following the principles of Plan-Do-Study-Act or PDSA, (Agency for Healthcare Research and Quality, 2008; Deming, 1986) as outlined in Table 8-1.
From page 298...
... Output to TABLE 8-1  Big Data Utilization Within a Continuous Learning System Using the IOM Learning System Framework Integrated with Plan-Do-Study-Act (PDSA) Principles Partnerships among Military Families, Science Providers, Leadership, Continuous and Informatics And Data Scientists Incentives Learning Culture Plan: Enable real-time Do: Engage and Study: Collect Act: Create a access to knowledge empower military meaningful data leadership-instilled and digital capture families in the data aligned with values culture of rigorous, of all components of being captured with in military families; continuous review the care experience data-use agreements create a fully of the data using for military families that emphasize transparent, data-safe algorithms supported in data-safe enhanced data system that avoids by machine learning environments.
From page 299...
... The real-time information in the outcomes portion of the model offers provider teams and families with performance measures, provider alerts, notifications on safety, quality, and value, and research data points, all of which can be used for future analyses as part of a larger monitoring effort. Military families need
From page 300...
... Military families need personalized predictions about well-being and response to services treatments. Big data initiatives allow for cluster-level queries with multilevel stratifications when evidence does not exist for a decision.
From page 301...
... At any rate, experts note that a challenge will be to put in place a system that specifies standards for data protection. Any big data learning system must strive to create safeguards that protect classified military information and have the highest levels of protection for military families.
From page 302...
... . G ­ handeharioun and colleagues conducted two randomized controlled trials examining different ways in which the Emotion-Aware mHealth Agent, or EMMA, improved individuals' well-being.
From page 303...
... . Mobile in Stepped-care Delivery Strategies Because mobile interventions can be disseminated conveniently and have the potential to promote behavioral change at low cost, they may have particular utility for stepped-care policies and adaptive interventions.
From page 304...
... The decision-making rules specify for each decision point what intervention option should be offered under various conditions. Specific Advantages of Adaptive Interventions for Military Families Adaptive interventions hold great potential for advancing the well-being of service members and their families in the ways they could support a complex adaptive MFRS.
From page 305...
... . address the varying needs of military families over time, concerning both within-person variation and within-family heterogeneity.
From page 306...
... . Developing Adaptive Interventions for Military Families Although multiple evidence-based adaptive interventions exist, limited attention has been given to the systematic development and implementation of adaptive interventions for military families.
From page 307...
... As an example of a current adaptive-intervention research effort underway for active duty families, the After Deployment, Adaptive Parenting Tools (ADAPT) Program is an intervention recently adapted to include mobile platforms to support delivery of prevention services with military families.
From page 308...
... At the same time, this can be done only by providing an intervention only when the person is receptive, namely able and willing to capitalize on a given intervention. Research on the behavioral health and adjustment implications of military deployments for families highlights the dynamic relationship between these military life experiences and military connected families as a source of both vulnerability and opportunity for personal growth.
From page 309...
... Learning from the implementation of evidence-based interventions in the contexts that serve military families enables the ongoing study of evidence-informed and evidence-based practice implementation, the monitoring of the impact of implementation on families, providers, and service systems, and the development of methods and measures that can serve to build tools for the field of implementation science.
From page 310...
... Second, some of the same interventions are delivered within and outside of the military context, and as such the implementation strategies to bring evidence-based interventions to military families can be simultaneously tested in external settings as well. The cross-context comparisons can help to isolate what characteristics of health care and community settings improve the adoption, implementation, and sustainability of interventions.
From page 311...
... discontinuation of a variety of evidence-based practices. A significant investment in applied research that identifies core mechanisms affecting implementation processes will produce value, most directly for military families and more indirectly for the larger implementation science community.
From page 312...
... CONCLUSION 8-4: An effective Military Family Readiness System requires a learning system framework that is data driven and culturally responsive to family and community diversity as well as to the complex and emergent challenges of military service. CONCLUSION 8-5: Military families and the Military Family Readi ness System will benefit from the utilization of big data and predictive analytics to monitor and tailor interventions that influence well-being at the level of the individual and the family.
From page 313...
... . Family-centered preventive intervention for military families: Implications for implementation science.
From page 314...
... . Application of Implementation Science to Population-based, Behavioral Health Prevention Continuum of Care for Military Families.
From page 315...
... . Leveraging big data to model the likelihood of developing psychological conditions after a concussion.
From page 316...
... . After deployment, adaptive parenting tools: One-year outcomes of a par enting program for military families.
From page 317...
... . Memo prepared for the Committee on the Well-Being of Military Families.
From page 318...
... . Evaluation of a family-centered preventive intervention for military families: Parent and child longitudinal outcomes.
From page 319...
... . Well-being of Military Families and a Learning Health System: The Importance of Data-Driven Decision Making.
From page 320...
... . Impact of Military Life on Children from Military Families.
From page 321...
... . Reducing barriers to evidence-based practice with military families: Clearinghouse for Military Family Readiness.
From page 322...
... . Mechanisms of risk and resilience in military families: theoretical and empirical basis of a family-focused resilience enhancement program.
From page 323...
... Paper commissioned by the Committee on the Well-Being of Military Families, Washington, DC, The National Academies of Sciences, Engineering, and Medicine. Tibbits, M


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