Adolescent Girls' Nutritional Status and Knowledge, Beliefs, Practices, and Access to Services: An Assessment to Guide Intervention Design in Nepal

BACKGROUND

Despite growing recognition of the importance of the adolescent period for health and nutritional well-being, scant evidence exists to inform interventions. Beyond limited understanding of adolescents' knowledge and practices, gaps in adolescent research also include limited understanding of how best to reach them with programs and policies and how the contexts in which they live present barriers and opportunities. Given that most studies on adolescent health and nutrition have used data from surveys of women of reproductive age, this study also sought to understand variation among younger and older adolescents and those who were already mothers.

OBJECTIVES

The primary aim was to support the design of an evidence-based adolescent program (Suaahara) in Nepal by describing adolescent girls' nutritional status; their exposure to information and services, knowledge, and practices in nutrition, health, family planning, and water, sanitation, and hygiene (WASH); and contextual factors; and to quantify variation by stage of adolescence.

METHODS

Using the first round (2017) from a panel of Nepalese adolescent girls, we categorized adolescent girls as: younger (10-14.9 y; n = 512), older (15-19.9 y; n = 325), and mothers (15-19.9 y; n = 256). Descriptive analyses generated proportions and means ± SDs, with statistical significance testing of differences.

RESULTS

The prevalence of underweight was highest in younger adolescents, whereas the prevalence of overweight/obesity in mothers was double that of the other 2 groups. More younger adolescents were in school, but fewer owned a mobile phone or had radio access. Exposure, knowledge, and behaviors across thematic areas also differed by stage of adolescence.

CONCLUSIONS

These findings have implications for Suaahara and other programs and policies aiming to support the health and nutritional well-being of adolescent girls. Heterogeneity among adolescent girls should be considered when identifying which interventions are needed and have the most potential for each subpopulation.

Assessing the Implementation of a Behavior Change Intervention: Process Evaluation of a Stepped-Wedge Cluster Randomized Controlled Trial for Newborn Health

Maternal and under five-year-old mortality rates have reduced in the last two decades globally due to concerted effort, yet newborn deaths remain unacceptably prevalent. Behavior change is an important component of interventions to address newborn health problems in low-income countries. In Cambodia, maternal and newborn mortality has markedly decreased, and continued improvements will allow the country to achieve further reduction in newborn morbidity. The results of an implementation study of the Newborn Care and Infection Control Initiative using process evaluation are presented to provide insight into the trial implementation and context of the program that may have contributed to intervention results. The study utilized a mixed method process to explore the context, mechanisms, and implementation of intervention components: training of village health support group volunteers to provide home visits, training of midwives on infection prevention and control around the perinatal period, counseling on newborn care, and provision of training materials for counseling and intervention. Implementation was evaluated through quantitative and qualitative data collection including surveys, observation, semi-structured interviews, focus groups, and visual media. Descriptive statistics summarized the quantitative data and thematic analysis was used to explore the qualitative data. The evaluation identified several factors that might have influenced the outcomes of the trial: continuity of health center staff communication, timing and ability to complete home visits, and training quality. Additional support for parents in the perinatal period, preferably provided at the community level, will contribute to further improvement in health outcomes for newborns in this area. Researchers in this context should consider mechanisms to improve the coordination of health facility staff counseling while providing support and resources to ensure home visits to families with newborns are made on time. Attention to staffing, training, and quality of newborn health interventions is critical in planning for the scaling-up of newborn health programming.

Usefulness and feasibility of comprehensive and less comprehensive vocational rehabilitation for patients with chronic musculoskeletal pain: perspectives from patients, professionals, and managers

PURPOSE

To explore the usefulness and feasibility of a comprehensive vocational rehabilitation (C-VR) program and less comprehensive (LC-VR) program for workers on sick leave due to chronic musculoskeletal pain, from the perspective of patients, professionals, and managers.

MATERIALS AND METHODS

Semi-structured interviews were held with patients, professionals, and managers. Using topic lists, participants were questioned about barriers to and facilitators of the usefulness and feasibility of C-VR and LC-VR. Thirty interviews were conducted with thirteen patients (n = 6 C-VR, n = 7 LC-VR), eight professionals, and nine managers. All interviews were transcribed verbatim. Data were analyzed by systematic text condensation using inductive thematic analysis.

RESULTS

Three themes emerged for usefulness ("patient factors," "content," "dosage") and six themes emerged for feasibility ("satisfaction," "intention to continue use," "perceived appropriateness," "positive/negative effects on target participants," "factors affecting implementation ease or difficulty," "adaptations"). The patients reported that both programs were feasible and generally useful. The professionals preferred working with the C-VR, although they disliked the fixed and uniform character of the program. They also mentioned that this program is too extensive for some patients, and that the latter would probably benefit from the LC-VR program. Despite their positive intentions, the managers stated that due to the Dutch healthcare system, implementation of the LC-VR program would be financially unfeasible.

CONCLUSIONS

The main conclusion of this study is that it is not useful to have one VR program for all patients with CMP and reduced work participation, and that flexible and tailored-based VR are warranted.Implications for rehabilitationBoth comprehensive and less comprehensive vocational rehabilitation are deemed useful for patients with chronic musculoskeletal pain and reduced work participation. Particular patient factors, for instance information uptake, discipline, willingness to change, duration of complaints, movement anxiety, obstructing thoughts, and willingness to return to work might guide the right program for the right patient.Both comprehensive and less comprehensive vocational rehabilitation are deemed feasible in practice. However, factors such as center logistic (schemes, rooms, professionals available) and country-specific healthcare insurance and sickness compensation systems should foster the implementation of less comprehensive programs.

Visualizing participant experiences in maternal and child nutrition studies using timeline mapping

Iron and folic acid (IFA) supplementation is one of the most cost-effective interventions to prevent and treat anemia during pregnancy. Despite having the highest global burden of anemia among pregnant women, rates of IFA uptake in pregnancy in India are still very low, particularly in the state of Uttar Pradesh. While there have been several studies that explored challenges around IFA consumption and adherence, there is a paucity of studies that have synthesized this information into a single visual tool that can help program implementers understand the challenges and identify potential areas of intervention.  Timeline maps were developed as a visual qualitative tool to explore the nuances of health behaviors among pregnant women with respect to antenatal care (ANC) services, including IFA consumption.  Timeline maps were used to visually document critical events pertaining to ANC services chronologically, including details on contact points with the health system and events specific to IFA distribution, consumption and counselling.  Six research assistants (RAs) were trained on how to use timeline maps and record participant narratives. The RAs later participated in a focus group discussion to gain insight about their experiences using the tool. RAs reported that the timeline maps were easy-to-use and facilitated in-depth conversations with participants. RAs shared that they were able to actively engage the participants in co-creating the maps. The visual nature of the tool prompted participants’ recall of key pregnancy events and reflexivity. Challenges reported with the tool/process included recollection of past events and potential misrepresentation of information. These highlight a need to restructure training processes. Our findings indicate that timeline maps have the potential to be used in a variety of other program contexts, and merit further exploration.

Visualizing participant experiences in maternal and child nutrition studies using timeline mapping

Iron and folic acid (IFA) supplementation is one of the most cost-effective interventions to prevent and treat anemia during pregnancy. Despite having the highest global burden of anemia among pregnant women, rates of IFA uptake in pregnancy in India are still very low, particularly in the state of Uttar Pradesh. While there have been several studies that explored challenges around IFA consumption and adherence, there is a paucity of studies that have synthesized this information into a single visual tool that can help program implementers understand the challenges and identify potential areas of intervention.  Timeline maps were developed as a visual qualitative tool to explore the nuances of health behaviors among pregnant women with respect to antenatal care (ANC) services, including IFA consumption.  Timeline maps were used to visually document critical events pertaining to ANC services chronologically, including details on contact points with the health system and events specific to IFA distribution, consumption and counselling.  Six research assistants (RAs) were trained on how to use timeline maps and record participant narratives. The RAs later participated in a focus group discussion to gain insight about their experiences using the tool. RAs reported that the timeline maps were easy-to-use and facilitated in-depth conversations with participants. RAs shared that they were able to actively engage the participants in co-creating the maps. The visual nature of the tool prompted participants' recall of key pregnancy events and reflexivity. Challenges reported with the tool/process included recollection of past events and potential misrepresentation of information. These highlight a need to restructure training processes. Our findings indicate that timeline maps have the potential to be used in a variety of other program contexts, and merit further exploration.

Health system decision-makers at the helm of implementation research: development of a framework to evaluate the processes and effectiveness of embedded approaches

Background

Embedded approaches to implementation research (IR), whereby health system decision-makers participate actively in the research process, are gaining traction as effective approaches to optimise the delivery of health programmes and policies. However, the evidence base on the processes and effectiveness of such collaborative research remains inchoate. Standardised approaches to evaluate these initiatives are needed to identify core elements of ‘embeddedness’, unveil the underlying pathways of change, and assess contribution to evidence uptake in decision-making and overall outcomes of effect. The framework presented in this paper responds to this need, designed to guide the systematic evaluation of embedded IR.

Methods

This evaluation framework for embedded IR approaches is based on the experience of a joint initiative by the Pan American Health Organization/Alliance for Health Policy and Systems Research, which has supported 19 IR grants in 10 Latin American and Caribbean countries from 2014 to 2017. The conceptualisation of this framework drew on various sources of information, including empirical evidence and conceptual insights from the literature, interviews with content experts, and a prospective evaluation of the 2016 cohort that included semi-structured key informant interviews, document analysis, and a research team survey to examine key aspects of embedded research.

Results

We developed a widely applicable conceptual framework to guide the evaluation of embedded IR in various contexts. Focused on uncovering how this collaborative research approach influences programme improvement, it outlines expected processes and intermediate outcomes. It also highlights constructs with which to assess ‘embeddedness’ as well as critical contextual factors. The framework is intended to provide a structure by which to systematically examine such embedded research initiatives, proposing three key stages of evidence-informed decision-making – co-production of evidence, engagement with research, and enactment of programme changes.

Conclusion

Rigorous evaluation of embedded IR is needed to build the evidence on its processes and effectiveness in influencing decision-making. The evaluation framework presented here addresses this gap with consideration of the complexity of such efforts. Its applicability to similar initiatives is bolstered by virtue of being founded on real-world experience; its potential to contribute to a nuanced understanding of embedded IR is significant.

Taxonomy of Seniors' Needs for Food and Food Assistance in the United States

Food insecurity results in poor health among seniors. Food and nutrition assistance targeted to seniors experiencing or at risk of food insecurity prevents poor health outcomes and enables seniors to age in place. Currently, the primary modes of service delivery are targeted to seniors who are older and frailer than average, rendering these modes less responsive to the needs of the broader population of food-insecure seniors and limiting the preventive potential of food assistance. This study aimed to understand needs among seniors for food and food assistance and to develop a comprehensive taxonomy for these needs. The taxonomy depicts seniors' self-identified needs that relate to their ability to access and use food and nutrition assistance across three domains: physical abilities, consuming food, and access and use of transportation. The results of this study are intended to provide in-depth information to support effective alignment of programs with seniors' needs.

Conflict Between Direct Experience and Research-Based Evidence Is a Key Challenge to Evidence-Based Respiratory Medicine on British Racing Yards

Inflammatory airway disease (IAD) is a commonly diagnosed but variably defined syndrome of equine lower airway inflammation. The most recent American College of Veterinary Internal Medicine (ACVIM) consensus statement, informed by research evidence, recommends a case definition based on clinical signs (poor performance or occasional coughing of at least 3 weeks duration), increased endoscopically-visible tracheal mucus, and bronchoalveolar lavage cytology, and proposes that the condition should be termed ‘mild-moderate equine asthma' (mEA). In British Thoroughbred racehorses, research to date has focused on airway inflammation defined by increased tracheal mucus and inflammatory tracheal wash sample cytology. It has been unclear whether or to what extent the ACVIM consensus statement has influenced the practice of British racing veterinarians. The aim of this qualitative study was to characterize and understand rationales for current practices relating to diagnosing and managing airway inflammation in British racehorses. Audio-recorded focus group discussions were conducted with 25 participants from four veterinary practices in England. Practices were purposively selected to represent those responsible for different types of racehorse, in different geographical regions. Thematic analysis of transcripts identified (i) an over-arching theme of serving the racing industry within which two further themes (ii) disregarding of the consensus and (iii) the pragmatic clinician were nested. The requirement to serve the racing industry was a key driver of clinical approaches, strongly influenced in particular by the trainer. Participants widely disregarded the consensus case definition of IAD/mEA for British racehorses because of perceived differences in etiology, perceived lack of practicability, particularly of BAL sampling, and perceived lack of understanding of the British racing context by consensus authors. Participants shared a strong professional identity as pragmatic clinicians providing an individualized clinical approach based on direct experience, which was often prioritized as the most valuable evidence with which to inform clinical decision-making. Lack of alignment with international consensus presents a barrier to practicing and furthering evidence-based medicine. Improved dialogue and partnership in research would be valuable and further research tailored for this population, including continuing development of contextually acceptable diagnostic methods, may be required.

The Emergence of a Sustainable Tobacco Treatment Program across the Cancer Care Continuum: A Systems Approach for Implementation at the University of California Davis Comprehensive Cancer Center

Tobacco treatment is increasingly recognized as important to cancer care, but few cancer centers have implemented sustainable tobacco treatment programs. The University of California Davis Comprehensive Cancer Center (UCD CCC) was funded to integrate tobacco treatment into cancer care. Lessons learned from the UCD CCC are illustrated across a systems framework with the Cancer Care Continuum and by applying constructs from the Consolidated Framework for Implementation Research. Findings demonstrate different motivational drivers for the cancer center and the broader health system. Implementation readiness across the domains of the Cancer Care Continuum with clinical entities was more mature in the Prevention domain, but Screening, Diagnosis, Treatment, and Survivorship domains demonstrated less implementation readiness despite leadership engagement. Over a two-year implementation process, the UCD CCC focused on enhancing information and knowledge sharing within the treatment domain with the support of the cancer committee infrastructure, while identifying available resources and adapting workflows for various cancer care service lines. The UCD CCC findings, while it may not be generalizable to all cancer centers, demonstrate the application of conceptual frameworks to accelerate implementation for a sustainable tobacco treatment program. Key common elements that may be shared across oncology settings include a state quitline for an adaptable intervention, cancer committees for outer/inner setting infrastructure, tobacco quality metrics for data reporting, and non-physician staff for integrated services.

Perspectives, Experiences, and Practices in the Use of Digital Information Technologies in the Management of Depression and Alcohol Use Disorder in Health Care Systems in Colombia

Digital information technologies are increasingly used in the treatment of mental health disorders. Through this qualitative study, researchers illuminated perspectives, experiences, and practices among diverse stakeholders in the use of digital information technologies in the management of depression and alcohol use disorders in Colombia. In-depth interviews and focus groups were conducted in five primary care institutions across Colombia. Thematic analysis was used to analyze the data. The use of technology in the treatment of mental health disorders can facilitate the evaluation and diagnosis, treatment, and promotion and prevention of mental health disorders, as well as multiple nonmental health applications in the primary care setting. Potential barriers to the use of technology in this setting include challenges of digital literacy, access to technology, confidentiality, and financing. This study can inform the implementation of digital information technologies in the care of depression and problematic alcohol use within health care systems in Colombia.

Evidence-based practice in child and adolescent mental health services - The challenge of implementing national guidelines for treatment of depression and anxiety

BACKGROUND

Mental health problems are one of the most pressing public health concerns of our time. Sweden has seen a sharp increase in mental disorders among children and youth during the last decade. The evidence base for treatment of psychiatric conditions has developed strongly. Clinical practice guidelines aim to compile such evidence and support healthcare professionals in evidence-based clinical decision-making. In Sweden, the national guidelines for the treatment of depression and anxiety disorders in children and adolescents were launched in 2010. The aim of this study was two folded, (i) to explore to what extent these guidelines were known and adhered to by health professionals in Child and Adolescent Mental Health Services and (ii) to investigate factors influencing implementation of the guidelines informed by the Consolidated Framework for Implementation Research.

METHODS

A qualitative approach was used, and data were collected through interviews with 18 health professionals in Child Mental Health Services in Sweden and a combination of conventional and directed content analyses was used. The Consolidated Framework for Implementation Research guided and structured data collection and analysis.

RESULTS

The guidelines were largely unknown by health professionals in Child Mental Health Services in all the clinics investigated. Adherence to guideline recommendations was reported as very low. Barriers to implementation were found in relation to the characteristics of the intervention, outer setting, inner setting and characteristics of the individuals involved.

CONCLUSIONS

The government initiative to develop and disseminate the guidelines seems to have made very little impact on health professionals' clinical practice. The guidelines were poorly aligned with the health professionals' knowledge and beliefs about effective mental health services for children and youth with depression and anxiety disorders. Suggestions for future efforts to improve the development and implementation of guidelines in Child Mental Health Services settings are given.

Implementation barriers for mHealth for non-communicable diseases management in low and middle income countries: a scoping review and field-based views from implementers

Background: Mobile health (mHealth) has been hailed as a potential gamechanger for non-communicable disease (NCD) management, especially in low- and middle-income countries (LMIC). Individual studies illustrate barriers to implementation and scale-up, but an overview of implementation issues for NCD mHealth interventions in LMIC is lacking. This paper explores implementation issues from two perspectives: information in published papers and field-based knowledge by people working in this field. Methods: Through a scoping review publications on mHealth interventions for NCDs in LMIC were identified and assessed with the WHO mHealth Evidence Reporting and Assessment (mERA) tool. A two-stage web-based survey on implementation barriers was performed within a NCD research network and through two online platforms on mHealth targeting researchers and implementors. Results: 16 studies were included in the scoping review. Short Message Service (SMS) messaging was the main implementation tool. Most studies focused on patient-centered outcomes. Most studies did not report on process measures and on contextual conditions influencing implementation decisions. Few publications reported on implementation barriers. The websurvey included twelve projects and the responses revealed additional information, especially on practical barriers related to the patients' characteristics, low demand, technical requirements, integration with health services and with the wider context. Many interventions used low-cost software and devices with limited capacity that not allowed linkage with routine data or patient records, which incurred fragmented delivery and increased workload. Conclusion: Text messaging is a dominant mHealth tool for patient-directed of quality improvement interventions in LMIC. Publications report little on implementation barriers, while a questionnaire among implementors reveals significant barriers and strategies to address them. This information is relevant for decisions on scale-up of mHealth in the domain of NCD. Further knowledge should be gathered on implementation issues, and the conditions that allow universal coverage.

Group Outdoor Health Walks Using Activity Trackers: Measurement and Implementation Insight from a Mixed Methods Feasibility Study

Outdoor walking groups are nature-based interventions (NBIs) that promote health and wellbeing by modifying individual behaviour. The challenges of such NBIs include the motivation of inactive adults to participate and measurement issues. This feasibility study investigates a 12-week group outdoor health walk (GOHW) incorporating activity trackers and use of a holistic health and wellbeing measure, the Self-sasessment of Change (SAC) scale. A mixed methods design explored participant recruitment and retention, programme delivery, and measures of physical activity and health and wellbeing. Walker data included: pre-post questionnaires, daily step counts, and interviews. Programme delivery information included: weekly checklists, staff reflections, stakeholder meeting minutes, and a report. Thirteen adults (age 63–81, 76% female) joined and completed the activity tracker GOHW. Activity trackers motivated walkers to join and be more active but complicated programme delivery. Activity trackers allowed the quantification of physical activity and the SAC health and wellbeing measure was easy to use. By week 12, all participants met national physical activity guidelines. Clinically relevant changes on the SAC scale included: sleeping well, experiencing vibrant senses, and feeling energised, focused, joyful, calm and whole. Results illustrate the feasibility of using activity trackers to motivate engagement in and provide a measure of physical activity from GOHWs. The SAC scale offers a promising measure for nature–health research. A conceptual model is provided for the development of future large-scale studies of NBIs, such as group outdoor health walks.

Time and Organizational Cost for Facilitating Implementation of Primary Care Mental Health Integration

BACKGROUND

Integrating mental health services into primary care settings is complex and challenging. Although facilitation strategies have successfully supported implementation of primary care mental health integration and other complex innovations, we know little about the time required or its cost.

OBJECTIVE

To examine the time and organizational cost of facilitating implementation of primary care mental health integration.

DESIGN

Descriptive analysis.

PARTICIPANTS

One expert external facilitator and two internal regional facilitators who helped healthcare system stakeholders, e.g., leaders, managers, clinicians, and non-clinical staff, implement primary care mental health integration at eight clinics.

INTERVENTION

Implementation facilitation tailored to the needs and resources of the setting and its stakeholders.

MAIN MEASURES

We documented facilitators' and stakeholders' time and types of activities using a structured spreadsheet collected from facilitators on a weekly basis. We obtained travel costs and salary information. We conducted descriptive analysis of time data and estimated organizational cost.

KEY RESULTS

The external facilitator devoted 263 h (0.09 FTE), including travel, across all 8 clinics over 28 months. Internal facilitator time varied across networks (1792 h versus 1169 h), as well as clinics. Stakeholder participation time was similar across networks (1280.6 versus 1363.4 person hours) but the number of stakeholders varied (133 versus 199 stakeholders). The organizational cost of providing implementation facilitation also varied across networks ($263,490 versus $258,127). Stakeholder participation accounted for 35% of the cost of facilitation activities in one network and 47% of the cost in the other.

CONCLUSIONS

Although facilitation can improve implementation of primary care mental health integration, it requires substantial organizational investments that may vary by site and implementation effort. Furthermore, the cost of using an external expert to transfer facilitation skills and build capacity for implementation efforts appears to be minimal.

Integrating Community Health Workers into Safety-Net Primary Care for Diabetes Prevention: Qualitative Analysis of Clinicians' Perspectives

BACKGROUND

Evidence shows community health workers (CHWs) can effectively deliver proven behavior-change strategies to prevent type 2 diabetes mellitus (diabetes) and enhance preventive care efforts in primary care for minority and low-income populations. However, operational details to integrate CHWs into primary care practice remain less well known.

OBJECTIVE

To examine clinicians' perceptions about working with CHWs for diabetes prevention in safety-net primary care.

SETTING

Clinicians are primary care physicians and nurses at two New York City safety-net hospitals participating in CHORD (Community Health Outreach to Reduce Diabetes). CHORD is a cluster-randomized trial testing a CHW intervention to prevent diabetes.

DESIGN

Guided by the Consolidated Framework for Implementation Research, we studied how features of the CHW model and organizational context of the primary care practices influenced clinicians' perspectives about the acceptability, appropriateness, and feasibility of a diabetes-prevention CHW program. Data were collected pre-intervention using semi-structured interviews (n = 18) and a 20-item survey (n = 54).

APPROACH

Both survey and interview questions covered clinicians' perspectives on diabetes prevention, attitudes and beliefs about CHWs' role, expectations in working with CHWs, and use of clinic- and community-based diabetes- prevention resources. Survey responses were descriptively analyzed. Interviews were coded using a mix of deductive and inductive approaches for thematic analysis.

KEY RESULTS

Eighty-seven percent of survey respondents agreed CHWs could help in preventing diabetes; 83% reported interest in working with CHWs. Ninety-one percent were aware of clinic-based prevention resources; only 11% were aware of community resources. Clinicians supported CHWs' cultural competency and neighborhood reach, but expressed concerns about the adequacy of CHWs' training; public and professional emphasis on diabetes treatment over prevention; and added workload and communication with CHWs.

CONCLUSIONS

Clinicians found CHWs appropriate for diabetes prevention in safety-net settings. However, disseminating high-quality evidence about CHWs' effectiveness and operations is needed to overcome concerns about integrating CHWs in primary care.

What Are the Barriers for Uptake of Antiretroviral Therapy in HIV-Infected Tuberculosis Patients? A Mixed-Methods Study from Ayeyawady Region, Myanmar

Antiretroviral therapy (ART) coverage among HIV-infected tuberculosis (HIV-TB) patients has been suboptimal in Myanmar and the reasons are unknown. We aimed to assess the ART uptake among HIV-TB patients in public health facilities of Ayeyawady Region from July 2017-June 2018 and explore the barriers for non-initiation of ART. We conducted an explanatory mixed-methods study with a quantitative component (cohort analysis of secondary programme data) followed by a descriptive qualitative component (thematic analysis of in-depth interviews of 22 providers and five patients). Among 12,447 TB patients, 11,057 (89%) were HIV-tested and 627 (5.7%) were HIV-positive. Of 627 HIV-TB patients, 446 (71%) received ART during TB treatment (86 started on ART prior to TB treatment and rest started after TB treatment). Among the 181 patients not started on ART, 60 (33%) died and 41 (23%) were lost-to-follow-up. Patient-related barriers included geographic and economic constraints, poor awareness, denial of HIV status, and fear of adverse drug effects. The health system barriers included limited human resource, provision of ART on 'fixed' days only, weaknesses in counselling, referral and feedback mechanism, and clinicians' reluctance to start ART early due to concerns about immune reconstitution inflammatory syndrome. We urge the national TB and HIV programs to take immediate actions to improve the ART uptake.

Designs and methods for implementation research: Advancing the mission of the CTSA program

INTRODUCTION

The US National Institutes of Health (NIH) established the Clinical and Translational Science Award (CTSA) program in response to the challenges of translating biomedical and behavioral interventions from discovery to real-world use. To address the challenge of translating evidence-based interventions (EBIs) into practice, the field of implementation science has emerged as a distinct discipline. With the distinction between EBI effectiveness research and implementation research comes differences in study design and methodology, shifting focus from clinical outcomes to the systems that support adoption and delivery of EBIs with fidelity.

METHODS

Implementation research designs share many of the foundational elements and assumptions of efficacy/effectiveness research. Designs and methods that are currently applied in implementation research include experimental, quasi-experimental, observational, hybrid effectiveness-implementation, simulation modeling, and configurational comparative methods.

RESULTS

Examples of specific research designs and methods illustrate their use in implementation science. We propose that the CTSA program takes advantage of the momentum of the field's capacity building in three ways: 1) integrate state-of-the-science implementation methods and designs into its existing body of research; 2) position itself at the forefront of advancing the science of implementation science by collaborating with other NIH institutes that share the goal of advancing implementation science; and 3) provide adequate training in implementation science.

CONCLUSIONS

As implementation methodologies mature, both implementation science and the CTSA program would greatly benefit from cross-fertilizing expertise and shared infrastructures that aim to advance healthcare in the USA and around the world.

Searching for published protocols of randomized controlled trials in primary health care: an empirical systematic approach

INTRODUCTION

Electronic search filters on family medicine or general practice studies have been developed and validated in previous work. However, there has been no systematic effort to specifically identify and record protocols of randomized controlled trials (RCT) protocols in primary health care (PHC). The aim of the present study was to systematically identify published RCT protocols in PHC and capture information about specific protocol characteristics that may describe this field.

METHODS

PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus from inception to December 2014 were systematically searched. Protocols of RCTs that were published in English and were relevant to PHC were considered as eligible. Protocols referred either to a mixed population, or to an intervention including a specialized part as well as pilot or feasibility trial protocols, were excluded. Specific protocol characteristics including publication year, country, prospective registration, funding, and publication sources were extracted.

RESULTS

The final database included 628 published RCT protocols (median publication year 2011; interquartile range 2009-2013). The majority of protocols were designed in the UK (n=141, 22.5%), the Netherlands (n=105, 16.7%), and USA (n=93, 14.8%). Research was mainly funded by the government (n=408, 65.0%) while 45 protocols (7.2%) included industry as the funding source. Two registries - International Standard Randomised Controlled Trials Number Registry (245 (42.9%)) and ClinicalTrials.gov (209 (36.6%)) - indexed most of the protocols. Journals from several scientific fields published the articles; the field of 'Primary Health Care Medicine, General and Internal' included 69 (11.0%) articles.

CONCLUSION

A compilation of published RCT protocols on PHC was feasible. The majority of protocols on PHC were published over the past 10 years, funded by the government and designed in three main countries.

Eight Priorities for Improving Primary Care Access Management in Healthcare Organizations: Results of a Modified Delphi Stakeholder Panel

OBJECTIVE

To identify priorities for improving healthcare organization management of patient access to primary care based on prior evidence and a stakeholder panel.

BACKGROUND

Studies on healthcare access show its importance for ensuring population health. Few studies show how healthcare organizations can improve access.

METHODS

We conducted a modified Delphi stakeholder panel anchored by a systematic review. Panelists (N = 20) represented diverse stakeholder groups including patients, providers, policy makers, purchasers, and payers of healthcare services, predominantly from the Veterans Health Administration. A pre-panel survey addressed over 80 aspects of healthcare organization management of access, including defining access management. Panelists discussed survey-based ratings during a 2-day in-person meeting and re-voted afterward. A second panel process focused on each final priority and developed recommendations and suggestions for implementation.

RESULTS

The panel achieved consensus on definitions of optimal access and access management on eight urgent and important priorities for guiding access management improvement, and on 1-3 recommendations per priority. Each recommendation is supported by referenced, panel-approved suggestions for implementation. Priorities address two organizational structure targets (interdisciplinary primary care site leadership; clearly identified group practice management structure); four process improvements (patient telephone access management; contingency staffing; nurse management of demand through care coordination; proactive demand management by optimizing provider visit schedules), and two outcomes (quality of patients' experiences of access; provider and staff morale). Recommendations and suggestions for implementation, including literature references, are summarized in a panelist-approved, ready-to-use tool.

CONCLUSIONS

A stakeholder panel informed by a pre-panel systematic review identified eight action-oriented priorities for improving access and recommendations for implementing each priority. The resulting tool is suitable for guiding the VA and other integrated healthcare delivery organizations in assessing and initiating improvements in access management, and for supporting continued research.

Mothering from the Inside Out: Adapting an evidence-based intervention for high-risk mothers in the Western Cape of South Africa

During South Africa's first two decades as a democracy, the Western Cape Province has undergone radical changes to its healthcare system in an effort to address the extensive socioeconomic inequities that remain in the aftermath of the apartheid era. Although progress has been made, there is a clear need for interventions that support parents and children receiving health services in the public sector who are vulnerable to multiple psychosocial risks associated with extreme poverty. In this mixed-method study, we examined the feasibility and acceptability of adapting an evidence-based parenting intervention called Mothering from the Inside Out that was developed for mothers who are vulnerable to similar risks in the United States. Using qualitative methods, we documented the collaborative process that was guided by principles of community-based participatory research and examined themes in the Western Cape collaborators' perspectives about the feasibility and acceptability of the intervention. Using quantitative methods, we tested the preliminary efficacy of the adapted version of Mothering from the Inside Out for improving maternal reflective functioning and mother-child interactions. Although findings from both study components indicated preliminary promise, a number of obstacles and challenges at multiple levels underscore the need for (a) flexibility and contextual support for intervention research conducted in under-resourced communities, (b) clinical sensitivity to the unique experiences of parents rearing children in highly stressful, under-resourced environments, and (c) equal partnerships that allow the expertise of local providers to inform the design proposals of consulting investigators.

Implementation barriers for mHealth for non-communicable diseases prevention and management in low and middle income countries: a scoping review and field-based views from implementers

Background: Mobile health (mHealth) has been hailed as a potential gamechanger for non-communicable disease (NCD) management, especially in low- and middle-income countries (LMICs). Individual studies illustrate barriers to implementation and scale-up, but an overview of implementation issues for NCD mHealth interventions in LMICs is lacking. This paper explores implementation issues from two perspectives: information in published papers and field-based knowledge by people working in this field. Methods: Through a scoping review publications on mHealth interventions for NCDs in LMICs were identified and assessed with the WHO mHealth Evidence Reporting and Assessment (mERA) tool. A two-stage web-based survey on implementation barriers was performed within a NCD research network and through two online platforms on mHealth targeting researchers and implementors. Results: 18 studies were included in the scoping review. Short Message Service (SMS) messaging was the main implementation tool. Most studies focused on patient-centered outcomes. Most studies do not report on process measures and on contextual conditions influencing implementation decisions. Few publications reported on implementation barriers. The websurvey included twelve projects and the responses revealed additional information, especially on practical barriers related to the patients' characteristics, low demand, technical requirements, integration with health services and with the wider context. Many interventions used low-cost software and devices with limited capacity that not allowing linkage with routine data or patient records, which incurred fragmented delivery and increased workload. Conclusion: Text messaging is a dominant mHealth tool for patient-directed of quality improvement interventions in LMICs. Publications report little on implementation barriers, while a questionnaire among implementors reveals significant barriers and strategies to address them. This information is relevant for decisions on scale-up of mHealth in the domain of NCD. Further knowledge should be gathered on implementation issues, and the conditions that allow universal coverage.

Early Intervention in Psychosis: Effectiveness and Implementation of a Combined Exercise and Health Behavior Intervention Within Routine Care

AIM

Young people with psychosis have higher rates of obesity, premature cardiovascular disease, and death compared to non-psychotic peers in the general population due to changes in metabolic regulation linked to antipsychotic medication and adverse health risk behaviors. The aim of this paper is to outline the development, implementation, and evaluation of a combined 12-week exercise and health behavior intervention delivered as part of an Early Intervention in Psychosis (EIP) routine service, within the UK.

METHODS

Participants (n = 27) completed a 12-week combined intervention program, engaging in weekly, 90-min sessions comprising a healthy behavior education session (45 min), followed by a facilitated exercise session (45 min). Anthropometric data from participants (n = 26) were collected at baseline, 12 weeks, and 12 months post-intervention. Health behaviors and clinical measurements were assessed at baseline and 12 months.

RESULTS

Mean baseline data suggests participants were at an increased health risk on entry to the program, with elevated values in mean body mass index (BMI; 70% overweight/obese), waist circumference, resting heart rate, and triglycerides. Fifty percent reported smoking daily, 64% ate < 5 fruits/vegetables per day, and 52% of participants were prescribed highly obesogenic antipsychotic medications (i.e., Olanzapine). At 12 weeks and 12 months, no changes were observed in mean BMI, waist circumference or any other clinical variable (p > 0.05). At 12 months, participants reported a positive impact on health behaviors including improved diet, increased physical activity levels, and cessation of substance use (n = 2), alcohol use (n = 2), and smoking (n = 4). Focus groups captured participant experiences, engagement with and satisfaction with the program, including challenges/barriers to program adherence.

CONCLUSIONS

The 12-week exercise and health behaviors program supported participants to attenuate their physical health risk which was sustained at 12-month follow-up. Self-reported positive health behavior changes are likely to have contributed to the prevention of excessive weight gain in this high-risk period. The evaluation was designed to have validity for a "real world EIP setting" and reflect the complexity of delivery to this participant group. Evaluation findings influenced subsequent commissioning of the physical health intervention as an ongoing element of routine EIP care within the participant site.

Application of the JA-CHRODIS Integrated Multimorbidity Care Model (IMCM) to a Case Study of Diabetes and Mental Health

The Integrated Multimorbidity Care Model (IMCM), developed by the Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS), proposes a set of 16 multidimensional components (i.e., recommendations) to improve the care of persons with multimorbidity in Europe. This study aimed at analyzing the potential applicability of the IMCM. We followed a qualitative approach that comprised two phases: (1) The design of a case study based on empirical clinical data, which consisted of a hypothetical woman with multimorbidity, type 2 diabetes mellitus, mental health, and associated social problems, and (2) the creation of a consensus group to gather the opinions of a multidisciplinary group of experts and consider the potential applicability of the IMCM to our case study. Experts described how care should be delivered to this patient according to each model component, suggested the use of specific rating scales and tools to assess her needs in a comprehensive and regular way, and pointed our crucial health and social resources to improve her care process. Experts also highlighted patient-centered, integrated and tailored care as one of the keystones of quality healthcare. Our results suggest that the IMCM is applicable in complex patients with multimorbidity.

Effects of PACK guide training on the management of asthma and chronic obstructive pulmonary disease by primary care clinicians: a pragmatic cluster randomised controlled trial in Florianópolis, Brazil

Introduction

The Practical Approach to Care Kit (PACK) guide was localised for Brazil, where primary care doctors and nurses were trained to use it.

Methods

Twenty-four municipal clinics in Florianópolis were randomly allocated to receive outreach training and the guide, and 24 were allocated to receive only the guide. 6666 adult patients with asthma or chronic obstructive pulmonary disease (COPD) were enrolled, and trial outcomes were measured over 12 months, using electronic medical records. The primary outcomes were composite scores of treatment changes and spirometry, and new asthma and COPD diagnosis rates.

Results

Asthma scores in 2437 intervention group participants were higher (74.8%, 20.4% and 4.8% with scores of 0, 1 and 2, respectively) than in 2633 control group participants (80.0%, 16.8% and 3.2%) (OR for higher score 1.32, 95% CI 1.08 to 1.61, p=0.006). Adjusted for asthma scores recorded in each clinic before training started, the OR was 1.24 (95% CI 1.03 to 1.50, p=0.022). COPD scores in 1371 intervention group participants (77.7%, 17.9% and 4.3% with scores of 0, 1 and 2) did not differ from those in 1181 control group participants (80.5%, 15.8% and 3.7%) (OR 1.21, 95% CI 0.94 to 1.55, p=0.142). Rates of new asthma and COPD diagnoses, and hospital admission, and indicators of investigation, diagnosis and treatment of comorbid cardiovascular disease, diabetes and depression, and tobacco cessation did not differ between trial arms.

Conclusion

PACK training increased guideline-based treatment and spirometry for asthma but did not affect COPD or comorbid conditions, or diagnosis rates.

Trial registration

NCT02786030 (https://clinicaltrials.gov/).

Portuguese (Brazil) Introdução

O guia de Abordagem Prática do Kit de Cuidados em Saúde (PACK) foi adaptado para o sistema de saúde do Brasil; médicos e enfermeiros da atenção primária foram treinados para usá-lo na pratica clínica.

Métodos

Vinte e quatro unidades básicas de saúde (UBS) municipais de Florianópolis foram alocadas aleatoriamente para receber treinamento nas UBS utilizando o guia, e 24 foram alocadas para receber apenas o guia. Foram analisados dados de 6.666 pacientes adultos com asma ou doença pulmonar obstrutiva crônica (DPOC) e os desfechos foram medidos por doze meses, através de registros médicos eletrônicos. Os resultados principais foram escores compostos de mudança no tratamento, realização de espirometria e taxas de novos diagnósticos de asma e DPOC.

Resultados

os escores de asma em 2437 participantes do grupo de intervenção foram maiores (74,8%, 20,4% e 4,8% com escores de 0, 1 e 2 respectivamente) do que em 2633 participantes do grupo controle (80,0%, 16,8% e 3,2%) (odds ratio (OR) para pontuação mais alta 1,32, intervalo de confiança de 95% (IC) 1,08-1,61, p = 0,006). Ajustado para os escores de asma registrados em cada clínica antes do início do treinamento, o OR foi de 1,24 (IC 95% 1,03-1,50, p = 0,022). Os escores da DPOC em 1371 participantes do grupo de intervenção (77,7%, 17,9% e 4,3% com escores de 0, 1 e 2) não diferiram dos de 1181 participantes do grupo controle (80,5%, 15,8% e 3,7%) (OR 1,21 (IC95% 0,94-1,55, p = 0,142) As taxas de novos diagnósticos de asma e DPOC, internação hospitalar e indicadores de diagnóstico e tratamento de co-morbidades cardiovasculares, diabete, depressão e cessação do tabagismo não diferiram entre os grupos experimentais.

Conclusão

O treinamento com PACK aumentou o tratamento baseado em diretrizes e espirometria para asma, mas não afetou as co-morbidades em DPOC ou as taxas de diagnóstico.

A Fortified Food Can Be Replaced by Micronutrient Supplements for Distribution in a Mexican Social Protection Program Based on Results of a Cluster-Randomized Trial and Costing Analysis

BACKGROUND

Despite positive nutrition impacts, the prevalence of malnutrition among beneficiaries of Mexico's conditional cash transfer (CCT) program remains high. Greater nutrition impact may have been constrained by the type of nutritional supplements provided.

OBJECTIVE

The objective of this study was to inform a potential modification to the supplements distributed to pregnant and lactating women and children.

METHODS

Impact was assessed using 2 cluster-randomized trials (pregnant women, children) run simultaneously. Communities (n = 54) were randomly assigned to the fortified foods provided by the program (Nutrivida women, Nutrisano children) or alternatives: tablets (women), syrup (children), or micronutrient powders for women (MNP-W) and children (MNP-C). Each supplement for women/children contained the same micronutrients based on the formulations of Nutrivida and Nutrisano, respectively. Pregnant women (aged >18 y) were recruited before 25 weeks of gestation and followed to 3 mo postpartum. Children aged 6-12 mo were recruited and followed to age 24 mo. Primary outcomes were anemia for women and length growth for children. Statistical analyses appropriate for cluster-randomized designs were used, and structural equation modeling to estimate dose-response effects. Supplement costs per beneficiary (daily dose for 18 mo) were estimated for production and distribution.

RESULTS

There was no significant difference in change of anemia prevalence between supplement groups in women, or in length growth between groups in children. One daily dose of any supplement was associated with 0.8 cm greater length growth. From baseline to age 24 mo, the prevalence of anemia in the Nutrisano, syrup, and MNP-C groups decreased by 36.7, 40.8, and 37.9 percentage points, respectively (within-group, P < 0.05; between groups, P > 0.05). Costs per beneficiary ranged from $12.1 (MNP-C) to $94.8 (Nutrivida).

CONCLUSIONS

The CCT program could distribute alternative supplements at lower cost per beneficiary without compromising potential for impact. Acceptance among beneficiaries should also be considered in choice of alternatives. This trial was registered at www.clinicaltrials.gov as NCT00531674.

Sociocultural Influences on Poor Nutrition and Program Utilization of Mexico's Conditional Cash Transfer Program

BACKGROUND

The impact of the Conditional Cash Transfer Program in Mexico was significant but smaller than expected. Several bottlenecks related to program design and implementation have been identified that may have limited its impact; population and other contextual factors may be equally important to analyze.

OBJECTIVES

We aimed to explore how sociocultural context contributes to poor nutrition in Mexico and how it shaped the acceptability, fidelity, and penetration of the fortified food and of education sessions provided by the program.

METHODS

We carried out qualitative research studies in the central and southern states in urban, rural, and indigenous settings between 2001 and 2014 with different informants and by using interviews, focus group discussions, and nonparticipatory observation. We explored 4 dimensions of the sociocultural context: objective dimension (e.g., food availability and family organization), social norms and symbolic meaning related to child feeding, literacy and communication with the biomedical culture, and knowledge related to child care generally and child feeding. We generated information about the experience of the beneficiaries with fortified food and education sessions.

RESULTS

Several sociocultural factors, including patriarchal family organization, high availability of nonnutritious food, social norms promoting the consumption of food in liquid form for young children, sharing of food among family members, traditional knowledge, and communication barriers with the biomedical culture, participated in shaping the poor nutrition situation, the inadequate utilization of fortified foods, and the inappropriateness of the education sessions.

CONCLUSIONS

Our studies revealed the importance of local context and culture to understand the acceptance, utilization, and impact of a nutrition program and shed light on infant and child feeding practices. This knowledge is critical to strengthen program designs and ensure adequacy with the diversity of cultural and social contexts in which programs are implemented.

Program Impact Pathways and Contexts: A Commentary on Theoretical Issues and Research Applications to Support the EsIAN Component of Mexico's Conditional Cash Transfer Program

This commentary on the Integrated Strategy for Attention to Nutrition (EsIAN) journal supplement begins with a discussion about the challenges that implementation researchers confront with respect to analyzing complex impact pathways. We note that the research on the implementation of the EsIAN component of Mexico's conditional cash transfer program was based implicitly or explicitly on a program impact pathway approach, which used both quantitative and qualitative methods to examine bottlenecks in program implementation. We then identify 5 categories of contexts that affect the impact, implementation, and survival of intervention programs: 1) biological, 2) social-cultural, 3) delivery modalities and platforms, 4) bureaucratic, and 5) political. Each of these contexts presents theoretical and methodological challenges for investigators. In this commentary, we focus primarily on biological and social-cultural contexts, discussing the theoretical and methodological challenges the investigators faced and the research strategies they used to address them, which have produced a unique compilation of "learning by doing" studies. We also touch briefly on the political context in which the Prospera program research was conducted. We conclude with statements that highlight the exceptional value of the journal supplement, not only with respect to the analysis of the interventions the studies cover and the sustained examination of a long-term program but also as a major contribution to the literature in implementation science in nutrition.

A Brief History of Evidence-Informed Decision Making for Nutrition in Mexico

The Progresa Conditional Cash Transfer program in Mexico began in 1997, with a strong evidence-based design. The program's ultimate objective was to foster the development of human capital through 3 components-education, health, and food. Rigorous impact evaluation generated evidence of impact on several outcomes, including child growth, but also aspects of program design and implementation challenges that may have limited impact. The objective of this supplement is to present research that led to the redesign of the health component, its implementation and evaluation at pilot scale, and its scale-up to national level, representing >15 y of collaboration among evaluators, program implementers, and funders. The studies used various methodologies, including process evaluation, cohort studies, ethnographic assessments, and a cluster-randomized trial, among others. The articles report previously unpublished results and citations of published literature. Article 1 uses an impact pathway to highlight gaps and bottlenecks that limited potential for greater impact, the original recognition of which was the impetus for this long collaboration. Article 2 explores the social and cultural factors that influence decisions to participate in programs and to adopt the actions proposed by them. Article 3 presents a cluster-randomized trial implemented to inform the choice of nutritional supplements for pregnant and lactating women and children 6-59 mo of age and how this and other evidence from the studies were used to redesign the health component of the program. Articles 4 and 5 present results of the development and pilot testing of the modified health component, the Integrated Strategy for Attention to Nutrition (abbreviated to EsIAN from its name in Spanish) (article 4), and the process and challenges of training and supervision in taking the EsIAN to scale (article 5). The final article provides reflections on the relevance of this body of work for implementation research in nutrition.

Implementation of government-directed policy in the hospital setting: a modified Delphi study

Background

In the last 20 years governments have sought to introduce policy that improves the quality of care provided in hospitals, yet little research has been done to understand how these policies are implemented, factors that affect the implementation process or what should be considered by decision-makers during policy development or implementation planning. Experts with real-life experience in the introduction and implementation of policy are best placed to provide valuable insight into practical issues that affect implementation and the associated outcomes of these policies.

Methods

A modified Delphi study of experts in hospital policy development and implementation was undertaken to investigate factors influencing the implementation of government-directed policy in the hospital setting. This study built on the findings of two previous studies — a qualitative study of clinician perspectives of policy implementation and a systematic review and meta-synthesis, in which common contextual factors and policy characteristics associated with policy implementation were ascertained. International experts with extensive experience in government-directed policy implementation at global, national, corporate, jurisdictional and organisational levels were asked to provide opinions on predetermined factors and the feasibility of considering these in policy development and implementation planning. Survey design and analysis was guided by the Consolidated Framework for Implementation Research.

Results

Eleven experts from four countries and with different health system perspectives participated in the study. Consensus was reached on the importance of all predetermined factors in the first survey round with additional factors for investigation highlighted by participants for examination in subsequent rounds. On study completion, expert consensus was reached on 24 factors of importance; only 20 of these factors reached consensus for feasibility.

Conclusions

Study findings indicated that, whilst there are multiple factors of importance in policy implementation across all Consolidated Framework for Implementation Research domains, some factors, such as establishment of roles and responsibilities for implementation and organisational lines of accountability, are feasible for consideration at a hospital level only. In addition, four factors did not reach consensus in terms of feasibility, indicating that it may not be practical to consider all factors of importance when implementing policy; this has important implications for implementation planning and resource allocation.

International Approach to Environmental and Lung Health. A Perspective from the Fogarty International Center

The global burden of lung disease is substantial, accounting for an estimated 7.5 million deaths per year, approximately 14% of annual deaths worldwide. The prime illnesses include, in descending order, chronic obstructive pulmonary disease, lung cancer, tuberculosis, acute respiratory infections, asthma, and interstitial lung fibrosis. Key risk factors include smoking, both indoor and outdoor air pollution, and occupational exposures. Although the distribution of both the diseases and the risk factors varies greatly by age, geography, and setting, the greatest burden falls on populations living in low- and middle-income countries. Improvements in these metrics will require major public health interventions to curb smoking; improving air quality both in the community and the household; addressing the ever-present burden of infections, including tuberculosis, flu, and the many agents that cause acute respiratory disease; and identifying and protecting workers from the hazards of exposure to toxic substances. Although research over the years has identified many ways to reduce or prevent the enormous burden of disease, a huge gap exists between what we know and what we can do. This "implementation gap" is the greatest challenge we face in this field today. Research on how best to address and implement the changes needed will require not only biomedical advances to improve treatment but also social, economic, and policy research. We still need to elaborate more effective evidence-based policies and interventions to control tobacco use, address ambient and household air pollution, and improve the prevention and treatment of tuberculosis and acute respiratory infections with vaccines and drugs and reduce exposures to environmental and occupational hazards. Until these efforts receive greater prioritization, the burden of disease is unlikely to diminish a great deal more.

Implementing Motivational Interviewing for Substance Misuse on Medical Inpatient Units: a Randomized Controlled Trial

BACKGROUND

General medical hospitals provide care for a disproportionate share of patients who misuse substances. Hospitalization provides a unique opportunity to identify and motivate patients to address their substance misuse.

OBJECTIVE

To determine the effectiveness of three strategies for implementing motivational interviewing for substance misuse with general medical inpatients.

DESIGN

Type 3 hybrid effectiveness-implementation randomized controlled trial (Clinical Trials.gov: NCT01825057).

PARTICIPANTS

Thirty-eight providers (physicians, physician assistants, nurses) from 13 general medical inpatient services, and 1173 of their patients admitted to an academically affiliated acute care hospital.

INTERVENTIONS

Implementation strategies included (1) a continuing medical education workshop on detection of substance misuse and provision of a motivational interview; (2) workshop plus bedside supervision (apprenticeship condition); and (3) a workshop plus ability to place a medical order for an interview from a consultation-liaison service (consult condition).

MAIN MEASURES

Primary outcomes were the percentage of study-eligible patients who received an interview for substance misuse and the integrity (adherence, competence) of the interviews. The secondary outcome was the percent of patient statements within the interviews that indicated motivation for reducing substance misuse.

KEY RESULTS

20.5% of patients in the consult condition received an interview, compared to 0.8% (Hedge's g = 1.49) and 3.0% (Hedge's g = 1.26) in the respective workshop only and apprenticeship conditions (p < 0.001). Motivational interviews in the consult condition were performed with more fundamental motivational interviewing adherence and competence than the other conditions. Most statements made by patients during the interviews favored reducing substance misuse, with no differences between conditions.

CONCLUSIONS

Providers' ability to place an order to have experts from the consultation-liaison service deliver a motivational interview was a more effective implementation strategy than a workshop or apprenticeship method for ensuring motivational interviewing is available to medical inpatients who misuse substances.

TRIAL REGISTRY

NCT01825057.

Human-centered design for global health equity

As digital technologies play a growing role in healthcare, human-centered design is gaining traction in global health. Amid concern that this trend offers little more than buzzwords, our paper clarifies how human-centered design matters for global health equity. First, we contextualize how the design discipline differs from conventional approaches to research and innovation in global health, by emphasizing craft skills and iterative methods that reframe the relationship between design and implementation. Second, while there is no definitive agreement about what the 'human' part means, it often implies stakeholder participation, augmenting human skills, and attention to human values. Finally, we consider the practical relevance of human-centered design by reflecting on our experiences accompanying health workers through over seventy digital health initiatives. In light of this material, we describe human-centered design as a flexible yet disciplined approach to innovation that prioritizes people's needs and concrete experiences in the design of complex systems.

Using the consolidated framework for implementation research (CFIR) to assess the implementation context of a quality improvement program to reduce missed opportunities for vaccination in Kano, Nigeria: a mixed methods study

Background: Although understanding implementation context is essential, there is a dearth of research on how to systematically explore it in quality improvement (QI) programs. Therefore, in this study, we used the consolidated framework for implementation research (CFIR) to guide a systematic evaluation of the implementation context of an ongoing QI program in order to generate rapid site-specific feedback that can be used to improve subsequent plan-do-study-act (PDSA) cycles.Methods: Formative cross-case evaluation was conducted using convergent mixed methods design. The study was conducted in five primary health care (PHC) facilities (PHC 1, PHC 3, PHC 5, PHC 9 and PHC 10) implementing the QI program. Health workers in those facilities formed the study population. Quantitative data were collected using a self-administered, Likert-based rating tool, while qualitative data collection was guided by an interview guide. The interviews were transcribed verbatim, and thematic analysis was performed. Raw median score and factor scores were computed. Methodological integration occurred at the design, analysis and reporting stage.Results: A total of 165 health workers were included in this study with a mean age of 33.43 years (standard deviation of 7.15). Majority were females and they all had post-secondary education. Health workers in two facilities; PHC 1 and PHC 5, reported higher score for the QI program across all five domains of CFIR. Implementation facilitators included intervention flexibility, relative advantage, self-efficacy among health workers, health workers confidence in the intervention, services integration. While implementation barriers included vaccine stock out, faulty cold chain infrastructure, lack of incentives, and socio-cultural beliefs.Conclusion: This study demonstrated that theory-driven formative evaluation can be integrated in QI programs in a low resource setting. It buttressed the value in conducting such assessment as they can be used to generate rapid feedback on factors that influence implementation success which can then be addressed in subsequent cycles.

Cardiovascular Diseases in African Americans: Fostering Community Partnerships to Stem the Tide

In 2002, the Institute of Medicine highlighted community partnerships as important in strategies for ensuring the public's health in the 21st century. Whether defined narrowly as the neighborhood or more broadly as the entire nation, communities represent settings in which health is supported and protected by healthy social connections and environments or risked and damaged by detrimental social, environmental, and policy determinants, as well as adverse behavioral and lifestyle choices. In this article, cardiovascular disease in African Americans is used as an example to highlight the successes achieved during the last half-century in reducing mortality rates, the persisting challenge of suboptimal adoption of evidence-based practices to promote community health and prevent disease, and the still widespread and pervasive health disparities. The article concludes with a call for the scientific community to embrace implementation research in strategic partnership with community stakeholders to stem the tide of cardiovascular disease and reduce related cardiovascular health disparities.

Implementation Research on Shared Decision Making in Primary Care: Inventory of Intracluster Correlation Coefficients

Background. Cluster randomized trials are important sources of information on evidence-based practices in primary care. However, there are few sources of intracluster correlation coefficients (ICCs) for designing such trials. We inventoried ICC estimates for shared decision-making (SDM) measures in primary care. Methods. Data sources were studies led by the Canada Research Chair in Shared Decision Making and Knowledge Transition. Eligible studies were conducted in primary care, included at least 2 hierarchical levels, included SDM measures for individual units nested under any type of cluster (area, clinic, or provider), and were approved by an ethics committee. We classified measures into decision antecedents, decision processes, and decision outcomes. We used Bayesian random-effect models to estimate mode ICCs and the 95% highest probability density interval (HPDI). We summarized estimates by calculating median and interquartile range (IQR). Results. Six of 14 studies were included. There were 97 ICC estimates for 17 measures. ICC estimates ranged from 0 to 0.5 (median, 0.03; IRQ, 0-0.07). They were higher for process measures (median, 0.03; IQR, 0-0.07) than for antecedent measures (0.02; 0-0.07) or outcome measures (0.02; 0-0.06), for which, respectively, "decisional conflict" (mode, 0.48; 95% HPDI, 0.39-0.57), "reluctance to disclose uncertainty to patients" (0.5; 0.11-0.89), and "quality of the decision" (0.45; 0.14-0.84) had the highest ICCs. ICCs for provider-level clustering (median, 0.06; IQR, 0-0.13) were higher than for other levels. Limitations. This convenience sample of studies may not reflect all potential ICC ranges for primary care SDM measures. Conclusions. Our inventory of ICC estimates for SDM measures in primary care will improve the ease and accuracy of power calculations in cluster randomized trials and inspire its further expansion in SDM contexts.

Implementation research for early childhood development programming in humanitarian contexts

Young children living in conditions of war, disaster, and displacement are at high risk for developmental difficulties that can follow them throughout their lives. While there is robust evidence supporting the need for early childhood development (ECD) in humanitarian settings, implementation of ECD programming remains sparse, largely due to the lack of evidence of how and why these programs can improve outcomes in humanitarian settings. In order to build the evidence base for ECD in humanitarian settings, we review the current state of implementation research for ECD programming (targeting children 0-8) in humanitarian settings, through a literature review and a series of key informant interviews. Drawing from existing frameworks of implementation research and the findings from our analysis, we present a framework for ECD implementation research in humanitarian settings and propose an agenda for future research.

Measuring the implementation of early childhood development programs

In this paper we describe ways to measure variables of interest when evaluating the implementation of a program to improve early childhood development (ECD). The variables apply to programs delivered to parents in group sessions and home or clinic visits, as well as in early group care for children. Measurements for four categories of variables are included: training and assessment of delivery agents and supervisors; program features such as quality of delivery, reach, and dosage; recipients' acceptance and enactment; and stakeholders' engagement. Quantitative and qualitative methods are described, along with when measures might be taken throughout the processes of planning, preparing, and implementing. A few standard measures are available, along with others that researchers can select and modify according to their goals. Descriptions of measures include who might collect the information, from whom, and when, along with how information might be analyzed and findings used. By converging on a set of common methods to measure implementation variables, investigators can work toward improving programs, identifying gaps that impede the scalability and sustainability of programs, and, over time, ascertain program features that lead to successful outcomes.

Implementation of the Symptom Navi © Programme for cancer patients in the Swiss outpatient setting: a study protocol for a cluster randomised pilot study (Symptom Navi© Pilot Study)

INTRODUCTION

Self-management interventions show promising results on symptom outcomes and self-management behaviours. The Symptom Navi© Programme (SN©P) is a nurse-led intervention supporting patients' symptom self-management during anticancer treatment. It consists of written patient information (Symptom Navi© Flyers (SN©Flyers)), semistructured consultations and a training manual for nurses.

METHODS AND ANALYSIS

This pilot study will evaluate the implementation of the SN©P based on the Reach Effectiveness-Adoption Implementation Maintenance framework at Swiss outpatient cancer centres. We will use a cluster-randomised design and randomise the nine participating centres to the intervention or usual care group. We expect to include 140 adult cancer patients receiving first-line systemic anticancer treatment. Trained nurses at the intervention clusters will provide at least two semistructured consultations with the involvement of SN©Flyers. Outcomes include patients' accrual and retention rates, patient-reported interference of symptoms with daily functions, symptom burden, perceived self-efficacy, quality of nursing care, nurse-reported facilitators and barriers of adopting the programme, nurses' fidelity of providing the intervention as intended, and patients' safety (patients timely reporting of severe symptoms). We will use validated questionnaires for patient-reported outcomes, focus group interviews with nurses and individual interviews with oncologists. Linear mixed models will be used to analyse patient-reported outcomes. Focus group and individual interviews will be analysed by thematic analysis.

ETHICS AND DISSEMINATION

The Symptom Navi© Pilot Study has been reviewed and approved by Swiss Ethic Committee Bern (KEK-BE: 2017-00020). Results of the study will be disseminated in peer-reviewed journal and at scientific conferences.

TRIAL REGISTRATION NUMBER

NCT03649984; Pre-results.

Implementation of the Identification and Referral to Improve Safety programme for patients with experience of domestic violence and abuse: A theory-based mixed-method process evaluation

Identification and Referral to Improve Safety (IRIS) is a training and support programme to improve the response to domestic violence and abuse (DVA) in general practice. Following a pragmatic cluster-randomised trial, IRIS has been implemented in over 30 administrative localities in the UK. The trial and local evaluations of the IRIS implementation showed an increase in referrals from general practice to third sector DVA services with a variation in the referral rates within and across practices. Using Normalisation Process Theory (NPT), we aimed to understand the reasons for such variability by identifying factors that influenced the implementation of IRIS in the National Health Service (NHS). We conducted a mixed-method process evaluation which included: (a) a case study (100 hr of participant observation, 19 interviews); (b) a survey (n = 118); (c) qualitative analysis of free-text comments from the survey; (d) qualitative interviews (n = 8); (e) document review (n = 44). Data were collected from NHS and third sector staff across five London boroughs from August 2015 to December 2017, analysed descriptively and thematically and triangulated using the NPT constructs coherence, cognitive participation, collection action and reflexive monitoring. The survey showed wide variation in the extent to which practice staff saw IRIS as a normal part of their daily work. Qualitative data and documents illuminated drivers of DVA work, implementation barriers and suggested solutions. The drivers were related to individual professional's characteristics and relationships. The barriers were linked to the differing sense-making and legitimisation of DVA work and differing contexts between the NHS and third sector. Solutions were adaptations to IRIS relative to these contextual differences. The suggested solutions can be used to update IRIS commissioning guidance, training for trainers and training for general practice. The updates should reflect the importance of ongoing support of IRIS from practice leads and commissioners, extended funding periods for IRIS and continuity of the IRIS team.

Stepped-wedge randomised trial to evaluate population health intervention designed to increase appropriate anticoagulation in patients with atrial fibrillation

BACKGROUND

Clinical guidelines recommend anticoagulation for patients with atrial fibrillation (AF) at high risk of stroke; however, studies report 40% of this population is not anticoagulated.

OBJECTIVE

To evaluate a population health intervention to increase anticoagulation use in high-risk patients with AF.

METHODS

We used machine learning algorithms to identify patients with AF from electronic health records at high risk of stroke (CHA₂DS₂-VASc risk score ≥2), and no anticoagulant prescriptions within 12 months. A clinical pharmacist in the anticoagulation service reviewed charts for algorithm-identified patients to assess appropriateness of initiating an anticoagulant. The pharmacist then contacted primary care providers of potentially undertreated patients and offered assistance with anticoagulation management. We used a stepped-wedge design, evaluating the proportion of potentially undertreated patients with AF started on anticoagulant therapy within 28 days for clinics randomised to intervention versus usual care.

RESULTS

Of 1727 algorithm-identified high-risk patients with AF in clinics at the time of randomisation to intervention, 432 (25%) lacked evidence of anticoagulant prescriptions in the prior year. After pharmacist review, only 17% (75 of 432) of algorithm-identified patients were considered potentially undertreated at the time their clinic was randomised to intervention. Over a third (155 of 432) were excluded because they had a single prior AF episode (transient or provoked by serious illness); 36 (8%) had documented refusal of anticoagulation, the remainder had other reasons for exclusion. The intervention did not increase new anticoagulant prescriptions (intervention: 4.1% vs usual care: 4.0%, p=0.86).

CONCLUSIONS

Algorithms to identify underuse of anticoagulation among patients with AF in healthcare databases may not capture clinical subtleties or patient preferences and may overestimate the extent of undertreatment. Changing clinician behaviour remains challenging.

Operational research: did health systems in Sierra Leone recover after the 2014-15 Ebola outbreak?

Findings from participants who attended the second post-Ebola SORT-IT course are reported in five short papers on the "legacy of Ebola on health Systems in Sierra-Leone". After a decline of health service provision and utilisation during the Ebola outbreak, present findings show recovery over time in the post-Ebola period. However, important challenges remain, including an important health workforce gap.

Strategies for Building Delivery Science in an Integrated Health Care System

Health systems today have increasing opportunities and imperatives to conduct delivery science, which is applied research that evaluates clinical or organizational practices that systems can implement or encourage. Examples include research on eliminating racial/ethnic disparities in hypertension management and on identifying the types of patients who can successfully use video visits. Clinical leaders and researchers often face barriers to delivery science, including limited funding, insufficient leadership support, lack of engagement between operational and research leaders, limited pools of research expertise, and lack of pathways to identify and develop ideas. We describe five key strategies we employed to address these barriers and develop a portfolio of delivery science programs in Kaiser Permanente Northern California. This portfolio now includes small and medium-sized grant programs, training programs for postdoctoral research fellows and experienced physician researchers, and a dedicated team that partners with clinicians to develop high-priority ideas and conduct small projects. Most of our approaches are consistent with frameworks used to develop delivery science by other health systems; some are innovative. Most of these strategies are adaptable by other health systems prepared to make long-range organizational commitments to mechanisms that foster partnerships between clinical leaders and researchers.

Stunted scale-up of a performance-based financing program on HIV and maternal-child health services in Mozambique - a policy analysis

OBJECTIVE

A performance-based financing (PBF) program was implemented for services for HIV, prevention of mother-to-child transmission (PMTCT) and maternal/child health (MCH) in two provinces of Mozambique. This study investigates the determinants of policy scale-up to help accelerate the expansion of PBF in Mozambique and globally from pilot projects to national policies.

METHODS

A retrospective policy programme analysis was carried out using in-depth key informant interviews. A total of 24 interviews were conducted with stakeholders from donor agencies, the implementing NGO, district and provincial health offices, and the Ministry of Health.

RESULTS

Stakeholders reported that the scale-up process of PBF was influenced by three key determinants: political power, financial sustainability, and available capacity and evidence. In Mozambique, PBF scaled-up provincially but not nationally due to these determinants. The adoption of PBF in Mozambique involved a restricted range of policy actors at the central level and was strongly driven by the donor and a PBF champion. Provincial scale-up was fostered by political support and increasing capacity over time.

CONCLUSION

There was a generalised ambivalence and lack of incentive to scale-up PBF from the implementing NGO. Coupled with the lack of evidence of a positive effect, and of cost-effectiveness in comparison with other models to improve health service delivery and health system strengthening, it is difficult to argue for the need to scale up the PBF programme studied. Care needs to be taken to base the adoption of health policies, including PBF, on a situational analysis and on evidence of intervention effectiveness, cost-benefits and contextual fit.

Barriers and facilitators to adopting functional maintenance initiatives for acutely hospitalised older adults

Purpose: To determine perceived barriers and facilitators to adopting and sustaining functional maintenance initiatives for acutely hospitalised older adults.Methods: A qualitative descriptive study using semi-structured interviews and initiative observations was conducted at five international and four Victorian acute hospitals. Purposive snowball sampling was used to recruit clinical, research, managerial, and volunteer staff who were involved in implementing and/or sustaining the initiatives. Emergent themes from audio-recorded interviews were developed and categorised as staff-perceived barriers or facilitators to adopting and sustaining initiatives using inductive thematic analysis.Results: Twenty-seven medical, nursing, allied health, and volunteer staff participated in interviews. Staff resistance and turnover, especially the loss of staff considered to be change drivers, were commonly reported barriers. A lack of professional autonomy was perceived to threaten longevity in allied health assistant led initiatives. Facilitators included support from change drivers, use of collaborative approaches and opinion leaders, integration of initiatives into usual care, alignment with institutional priorities, use of "internal" evidence to justify ongoing institutional investment, and use of an accompanying training and evaluation strategy.Conclusions: Successful adoption and sustainability of functional maintenance initiatives for acutely hospitalised older adults are influenced by a range of "non-clinical" factors, such as the ongoing effectiveness of change drivers. These factors should be considered when deciding upon future innovations to address functional decline and its associated economic impact.IMPLICATIONS FOR REHABILITATIONConsidering barriers and facilitators to successful adoption of functional maintenance initiatives is important for implementing evidence-based practice targeting the prevention of functional decline in acutely hospitalised older adults.Change drivers who remain actively involved are core facilitators of successful functional maintenance initiative adoption.Credible "internal" evaluation data are essential for ongoing sustainability of functional maintenance initiatives.Continual staff training is a key feature of successful functional maintenance initiatives.Perceived financial barriers to adopting functional maintenance initiatives can be overcome by other facilitating influences.

Staff Perspectives on Primary Care Teams as De Facto "Hubs" for Care Coordination in VA: a Qualitative Study

BACKGROUND

Improving care coordination is a key priority for many healthcare systems. However, initiatives to improve care coordination are complex to implement and have produced mixed results. A better understanding of how to craft and support implementation of effective care coordination strategies is needed.

OBJECTIVE

To identify and understand the challenges and factors encountered by Patient-Aligned Care Team (PACT) staff in performing care coordination tasks in outpatient clinics in the Veterans Health Administration (VA).

DESIGN

Qualitative study using semi-structured formative evaluation interviews.

PARTICIPANTS

Fourteen interviews with 18 clinical frontline managers and staff from 12 clinic sites across five VA health systems.

INTERVENTIONS

This paper reports on baseline data collected for the Coordination Toolkit and Coaching (CTAC) project. CTAC aims to improve patients' experience of care coordination within VA primary care and between PACT and other outpatient and community settings.

APPROACH

We conducted pre-implementation telephone interviews with frontline managers and staff, primarily nurse managers.

KEY RESULTS

PACT staff described challenges in aligning care coordination priorities across different levels of the VA system, including staff, patients, and leadership. Additionally, PACT staff noted challenges coordinating care both within and outside the VA, and identified resource barriers impeding their care coordination efforts. To address these challenges, staff made several recommendations for improvement, including (1) contingency staffing to address staff burnout; (2) additional PACT training for new staff; (3) clarification of care coordination roles and responsibilities; and (4) and care coordination initiatives that align both with centrally initiated care coordination programs and frontline needs.

CONCLUSION

In the VA and similarly complex healthcare systems, our findings suggest the need for care coordination strategies that are buttressed by a system-level vision for care coordination, backed up by clear roles and responsibilities for information exchange between primary care staff and other settings, and multidimensional accountability metrics that encompass patient-, staff-, and system-level goals.

Designing and implementing an integrated non-communicable disease primary care intervention in rural Nepal

Low-income and middle-income countries are struggling with a growing epidemic of non-communicable diseases. To achieve the Sustainable Development Goals, their healthcare systems need to be strengthened and redesigned. The Starfield 4Cs of primary care-first-contact access, care coordination, comprehensiveness and continuity-offer practical, high-quality design options for non-communicable disease care in low-income and middle-income countries. We describe an integrated non-communicable disease intervention in rural Nepal using the 4C principles. We present 18 months of retrospective assessment of implementation for patients with type II diabetes, hypertension and chronic obstructive pulmonary disease. We assessed feasibility using facility and community follow-up as proxy measures, and assessed effectiveness using singular 'at-goal' metrics for each condition. The median follow-up for diabetes, hypertension and chronic obstructive pulmonary disease was 6, 6 and 7 facility visits, and 10, 10 and 11 community visits, respectively (0.9 monthly patient touch-points). Loss-to-follow-up rates were 16%, 19% and 22%, respectively. The median time between visits was approximately 2 months for facility visits and 1 month for community visits. 'At-goal' status for patients with chronic obstructive pulmonary disease improved from baseline to endline (p=0.01), but not for diabetes or hypertension. This is the first integrated non-communicable disease intervention, based on the 4C principles, in Nepal. Our experience demonstrates high rates of facility and community follow-up, with comparatively low lost-to-follow-up rates. The mixed effectiveness results suggest that while this intervention may be valuable, it may not be sufficient to impact outcomes. To achieve the Sustainable Development Goals, further implementation research is urgently needed to determine how to optimise non-communicable disease interventions.

Public Health Panorama of Operational Research: A Narrative Review

Operational research (OR) is a relatively new, applied branch of mathematics, which helps provide a scientific base for the management and problem-solving. At present, its application in public health issues is gaining importance both nationally and internationally, particularly in program management and policy making. It is an interdisciplinary team approach that requires managers and researchers to work together toward identification of the problems and implementation of optimal solutions. There is rising importance accorded by international and national agencies to invest resources in OR and guide program implementation in public health, and the global fund to fight TB, AIDS, and malaria allows up to 10% of each grant to be allocated for OR. There are multitude of research methods used in the field of health. These fields of OR, implementation research, and health system research are a source of confusion for researchers. OR may sometimes be used interchangeably with implementation research or under the subheading of health system research. OR using various qualitative and mathematical models provides solutions which are currently being applied to overcome the obstacles in health policy making and implementation. Integration of OR with monitoring and evaluation is a new paradigm in program management. This paper aims to summarize the theme, relevance, approach, methods, and applications and challenges of OR in the field of public health and how it had led to policy changes in the field of health.

A Qualitative Study of Primary Care Providers' Experiences with the Veterans Choice Program

BACKGROUND

The Veterans Access, Choice and Accountability Act (hereafter, Choice Program) seeks to improve access to care by enabling eligible Veterans to receive care from community providers. Veterans Affairs (VA) primary care providers (PCPs) play a key role in making referrals to community specialists, but their frontline experiences with referrals are not well understood.

OBJECTIVE

To understand VA PCPs' experiences referring patients to community specialists while VA works to expand and refine the implementation of the Choice Program.

DESIGN

Qualitative study using interview methods.

PARTICIPANTS

Semi-structured telephone interviews were conducted with VA primary care providers (N = 72 out of 599 contacted) recruited nationally.

APPROACH

Open-ended interview questions elicited PCP perceptions and experiences with referrals to community specialists via the Choice Program. Keywords were identified using automated coding features in ATLAS.ti and evaluated using conventional content analysis to inductively describe the qualitative data.

KEY RESULTS

VA PCPs emphasized problems with care coordination and continuity between the VA and community specialists (e.g., "It is extremely difficult for us to obtain and continue continuity of care because there's not much communication with the community specialist"). They described difficulties with tracking the initial referral, coordinating care after receiving community specialty care, accessing community medical records, and aligning community specialists' prescriptions with the VA formulary.

CONCLUSIONS

The VA Choice Program provides access to community specialists for VA patients; however, VA primary care providers face challenges tracking referrals to community specialists and in coordinating care. Strategies to improve care coordination between the VA and community providers should focus on providing PCPs with information to follow Veterans throughout the Choice referral process and follow-up.

Acceptability and challenges of introducing an educational audio-drama about gender violence and HIV prevention into schools in Botswana: an implementation review

Structural interventions for HIV prevention are typically complex and evaluation should include measurement of implementation. In a trial of a structural intervention for HIV prevention in Botswana we trained teachers to use an audio-drama about gender violence and HIV (BVV). We measured the use of BVV by the trained teachers, and the factors related. In three-day workshops we trained guidance teachers in primary and secondary schools to use the 8-episode BVV audio-drama, that covers gender, gender violence and HIV. One to two years later, two interviewers visited schools and administered an electronic questionnaire to the head teacher and to the BVV-trained teacher. Most teachers (70%, 72/103) had used the BVV materials and reported a positive response from students. Primary school teachers were less likely to have used BVV (adjusted odds ratio (ORa) 0.24, 95% cluster adjusted confidence interval (CIca) 0.07-0.88). Teachers in schools with a working MP3 player were more likely to have used BVV (ORa 3.75, 95% CIca 1.11-12.70). Implementation was much lower in one district (ORa 0.12, 95% CIca 0.04-0.36), related to language constraints. The main difficulty was lack of time, especially in primary schools. These findings could inform rollout of the BVV programme in schools. Abbreviations: BVV: Beyond Victims and Villains audio-drama; CI: Confidence interval; OR: Odds ratio.

Qualitative evaluation of a complex intervention to implement health promotion activities according to healthcare attendees and health professionals: EIRA study (phase II)

OBJECTIVE

To evaluate the implementation and development of a complex intervention on health promotion and changes in health-promoting behaviours in primary healthcare according to healthcare attendees and health professionals.

DESIGN

Descriptive qualitative evaluation research conducted with 94 informants. Data collection techniques consisted of 14 semistructured individual interviews, 9 discussion groups, 1 triangular group and 6 documents. Three analysts carried out a thematic content analysis with the support of Atlas.ti software. This evaluation was modelled on Proctor and colleagues' concept of outcomes for implementation research.

SETTING

7 primary care centres from seven Spanish regions: Andalusia, Aragon, Balearic Islands, Basque Country, Castilla-La Mancha, Castilla-Leon and Catalonia.

PARTICIPANTS

The study population were healthcare attendees (theoretical sampling) and health professionals (opportunistic sampling) who had participated in the exploratory trial of the EIRA intervention (2015).

RESULTS

Healthcare attendees and professionals had a positive perception of the study. Healthcare attendees even reported that they would recommend participation to family and friends. Health professionals became aware of the significance of the motivational interview, especially for health promotion, and emphasised social prescribing of physical activity. They also put forward recommendations to improve recruitment, screening and retention of participants. Healthcare attendees modified behaviours and health professionals modified working practices. To achieve sustainability, health professionals believe that it is crucial to adapt agendas and involve all the staff.

CONCLUSIONS

The discourses of all stakeholders on the intervention must be taken into consideration for the successful, setting-specific implementation of adequate, acceptable, equitable and sustainable strategies aimed at health promotion and well-being.