Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework

Interprofessional education interventions for healthcare professionals to improve patient safety: a scoping review

BACKGROUND

Patient safety incidents, such as adverse events and medical errors, are often caused by ineffective communication and collaboration. Interprofessional education is an effective method for promoting collaborative competencies and has attracted great attention in the context of patient safety. However, the effectiveness of interprofessional education interventions on patient safety remains unclear. This scoping review aimed to synthesize existing studies that focused on improving patient safety through interprofessional education interventions for healthcare professionals.

METHODS

Six databases, including Medline (via PubMed), Embase, Cochrane Library, CINAHL (via EBSCO), Scopus and Web of Science, were last searched on 20 December 2023. The search records were independently screened by two researchers. The Joanna Briggs Institute Critical Appraisal Tool for Quasi-Experimental Studies was used for quality appraisal. The data were extracted by two researchers and cross-checked. Finally, a narrative synthesis was performed. The protocol for this scoping review was not registered.

RESULTS

Thirteen quasi-experimental studies with moderate methodological quality were included. The results revealed that the characteristics of current interprofessional education interventions were diverse, with a strong interest in simulation-based learning strategies and face-to-face delivery methods. Several studies did not assess the reduction in patient safety incidents involving adverse events or medical errors, relying instead on the improvements in healthcare professionals' knowledge, attitude or practice related to patient safety issues. Less than half of the studies examined team performance, based primarily on the self-evaluation of healthcare professionals and observer-based evaluation. There is a gap in applying newer tools such as peer evaluation and team-based objective structured clinical evaluation.

CONCLUSION

Additional evidence on interprofessional education interventions for improving patient safety is needed by further research, especially randomized controlled trials. Facilitating simulation-based interprofessional education, collecting more objective outcomes of patient safety and selecting suitable tools to evaluate teamwork performance may be the focus of future studies.

Barriers and facilitators for healthy lifestyle and recommendations for counseling in endometrial cancer follow-up care: a qualitative study

OBJECTIVES

Lifestyle promotion during follow-up consultations may improve long-term health and quality of life in endometrial cancer patients. This study aimed to identify barriers and facilitators to improve and sustain a healthy lifestyle that can be translated to behavioral methods and strategies for lifestyle counseling.

METHODS

Endometrial cancer patients from three hospitals were recruited to participate in a semi-structured interview. The data were transcribed and coded. Thematic analysis was applied to identify themes and the behavior change wheel was used as a theoretical framework. Data saturation was confirmed after 18 interviews.

RESULTS

Barriers included knowledge gaps as well as lack of motivation and environmental opportunities to engage in health-promoting behavior. Facilitators included applying incremental lifestyle changes, social support, positive reinforcements, and the ability to overcome setbacks.

CONCLUSIONS

We propose the following intervention functions: education, persuasion, training, environmental restructuring, and enablement. Suitable behavior change techniques to deliver the intervention functions include information about the consequences of certain behavior, feedback on behavior, credible source, graded tasks, habit formation, restructuring of the environment, prompts/cues, goal setting, action planning, and social support. Including these recommendations in lifestyle counseling could aid lasting lifestyle change since it suits the needs and preferences of patients.

Improving antibiotic use in hospitals: development of a digital antibiotic review tracking toolkit (DARTT) using the behaviour change wheel

OBJECTIVE

To develop a theory-informed behaviour change intervention to promote appropriate hospital antibiotic use, guided by the Medical Research Council's complex interventions framework.

METHODS

A phased approach was used, including triangulation of data from meta-ethnography and two qualitative studies. Central to intervention design was the generation of a robust theoretical basis using the Behaviour Change Wheel to identify relevant determinants of behaviour change and intervention components. Intervention content was guided by APEASE (Acceptability, Practicability, Effectiveness, Affordability, Side-effects, and Equity) criteria and coded using a Behaviour Change Technique Taxonomy. Stakeholders were involved throughout.

RESULTS

From numerous modifiable prescribing behaviours identified, active 'antibiotic time-out' was selected as the target behaviour to help clinicians safely initiate antibiotic reassessment. Prescribers' capability, opportunity, and motivation were potential drivers for changing this behaviour. The design process resulted in the selection of 25 behaviour change techniques subsequently translated into intervention content. Integral to this work was the development and refinement of a Digital Antibiotic Review Tracking Toolkit.

CONCLUSION

This novel work demonstrates how the Behaviour Change Wheel can be used with the Medical Research Council framework to develop a theory-based behaviour change intervention targeting barriers to timely hospital antibiotic reassessment. Future research will evaluate the Antibiotic Toolkit's feasibility and effectiveness.

Barriers and enablers to addressing smoking, nutrition, alcohol consumption, physical activity and gestational weight gain (SNAP-W) as part of antenatal care: A mixed methods systematic review

BACKGROUND

International clinical guidelines recommend that smoking, nutrition, alcohol consumption, physical activity and gestational weight gain (SNAP-W) be addressed as part of routine antenatal care throughout pregnancy. However, guideline recommendations are poorly implemented, and few antenatal care recipients routinely receive the recommended care. There is a need to establish the determinants (barriers and enablers) to care delivery to inform strategies to improve implementation. This systematic review aimed to synthesize qualitative and quantitative evidence of the barriers and enablers to the routine delivery of antenatal care targeting SNAP-W health risks.

METHODS

A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Seven databases were searched for relevant studies published between January 2001 and November 2023. Study findings were coded and analysed according to the domains of the Theoretical Domains Framework (TDF).

RESULTS

Forty-nine studies were included in the review, 27 qualitative studies and 22 quantitative studies. The studies were conducted in 14 countries. Data were collected from 7146 antenatal care providers (midwives, Aboriginal health workers, obstetricians, medical officers, general practitioners) and 352 barriers and enablers were identified. Across all SNAP-W health risk and antenatal care provider groups, the predominant TDF domain was 'environmental context and resources', identified in 96% of studies. Barriers within this domain included insufficient time, limited access to and quality of resources, and limited organisational supports. 'Beliefs about consequences' was the second most common TDF domain, reported in 67% of studies, particularly studies of care related to alcohol use, nutrition/ physical activity/ gestational weight gain and those involving midwives, multidisciplinary practitioners and general practitioners. 'Optimism' was the second most common TDF domain for studies of smoking-related care and involving obstetricians, gynaecologists, and other mixed medical professions.

CONCLUSIONS

It is critical that determinants related to environmental context and resources including time, resources and organisational supports are considered in the development of strategies to support the implementation of recommended antenatal care related to SNAP-W risks. Strategies addressing clinician beliefs about consequences and optimism may also be needed to support the implementation of care related to specific health behaviours and by specific antenatal care provider groups.

REGISTRATION

The review protocol was prospectively registered with Prospero: CRD42022353084; 22 October 2022.

Translating acceptability to sustained delivery: Clinician and manager perspectives on implementing modified constraint-induced movement therapy in an early-supported discharge rehabilitation service

BACKGROUND

Modified constraint-induced movement therapy (mCIMT) improves upper limb (UL) function after stroke. Despite up to one-third of stroke survivors being eligible, clinical uptake remains poor. To address this, a multi-modal behaviour change intervention was implemented across a large seven-site early-supported discharge (ESD) rehabilitation service. This study investigated the acceptability of mCIMT implementation within this ESD service and identified adaptations required for sustained delivery.

METHODS

This qualitative study was nested within a mixed-methods process evaluation of mCIMT implementation. Four focus groups (n = 24) comprising therapists (two groups), therapy assistants (one group), and allied health managers (one group) were conducted. Data were analysed using reflexive thematic analysis and mapped to the Theoretical Domains Framework (TDF).

CONSUMER AND COMMUNITY INVOLVEMENT

Consumers were not directly involved in this study; however, lived experience research partners have helped shape the larger mixed-methods implementation study.

FINDINGS

Four themes were generated and mapped to the TDF. Factors related to acceptability included interdisciplinary practice in sharing workloads (belief about capabilities), practice opportunities across a range of UL presentations (skills), clinician attitudes influencing patient engagement (optimism), time constraints (belief about consequences), and cognitive overload from multiple systems and processes (memory, attention, and decision-making processes). Factors facilitating sustained delivery included improving stroke survivor education (knowledge), sharing success stories across teams (reinforcement), manager facilitation (social/professional role and identity), and the perception that the ESD setting was optimal for mCIMT delivery (social influences).

CONCLUSION

mCIMT was acceptable in the ESD service, with clinicians feeling a responsibility to provide it. Key adaptations for sustained delivery included ongoing training, resource adaptation, and enhanced patient and carer engagement. Successful implementation and sustained delivery of mCIMT in the ESD service could enhance UL function and reduce the burden of care for potentially hundreds of stroke survivors and their carers.

PLAIN LANGUAGE SUMMARY

Modified constraint-induced movement therapy (mCIMT) helps improve arm movement after a stroke. However, many stroke survivors do not get this therapy. To fix this, we started a program in a large home-based rehabilitation service. This study looked at how well mCIMT could fit into this service. We also wanted to know what changes were needed to make sure it was regularly provided. We held four group discussions with therapists, therapy assistants, and health managers. A total of 24 people took part. From these discussions, we found several important points. Therapists needed to work together as a team. They also needed to practice mCIMT to get better at delivering it. Therapists having a positive attitude would encourage more stroke survivors to take part. For long-term success, stroke survivors need better education about mCIMT. Managers need to encourage therapists to provide mCIMT. The rehabilitation service should also share their success stories about this therapy to encourage therapists to deliver it and stroke survivors to ask for it. Therapists enjoyed delivering mCIMT in the rehabilitation service. It worked better than other therapies to improve a stroke survivor's arm function. Because of this, they also felt it was their duty to offer mCIMT. Having ongoing training and better resources would help keep mCIMT going. If mCIMT can be provided regularly in this service, it could lead to better arm function and less care needed for many stroke survivors and their carers.

Developing a shared language: a proposed guide to frame early implementation science collaboration discussions

Miscommunication between health care practitioners and implementation researchers can lead to a mismatch of expectations and understandings, resulting in wasted research and frustration. Conversely, combining the expertise and knowledge of those working in health care practice and implementation research can deliver context informed research questions and appropriate study designs. Achieving this ambition requires a shared language. We sought to develop a guide to identify a common language to constructively explore nascent implementation research concepts. We set up a working group, comprising of implementation researchers, health care practitioners and operational managers, to work through ideas generation, debate and a consensus process to generate and refine a discussion guide. The resultant guide steps health care practitioners and implementation researchers through a three-phase enquiry - Question 1: What is the implementation question? Question 2: What is the proposed implementation solution? And Question 3: How can the investigation of this idea be resourced? At each step, the health care practitioner and implementation researcher collaborate to include theory and practice and rigorously work through the question to build implementation on evidence and to promote diverse stakeholder engagement. The next steps for this study will be operationalising the discussion guide, as an interactive tool. Future evaluation, to test effectiveness, acceptability and feasibility will be designed with health care practitioners and implementation researchers.

Theory-based physical activity and/or nutrition behavior change interventions for cancer survivors: a systematic review

PURPOSE

Theory-based interventions aimed at promoting health behavior change in cancer survivors seem to be effective but remain scarce. More information on intervention features is also needed. This review aimed to synthesize the evidence from randomized controlled trials evaluating the efficacy of theory-based interventions (and its features) on physical activity (PA) and/or diet behaviors in cancer survivors.

METHODS

A systematic search in three databases (PubMed, PsycInfo, and Web of Science) identified studies that (i) targeted adult cancer survivors and (ii) included theory-based randomized controlled trials designed to influence PA, diet, or weight management. A qualitative synthesis of interventions' effectiveness, extensiveness of theory use, and applied intervention techniques was conducted.

RESULTS

Twenty-six studies were included. Socio-Cognitive Theory was the most used theory, showing promising results in PA-only trials and mixed findings in multiple-behavior interventions. Mixed findings were observed for interventions based on the Theory of Planned Behavior and Transtheoretical Model. Limited findings were found in diet-only interventions. A large variability in the extensiveness of theory use, and in intervention techniques was found. Further research is required to understand how and why these interventions offer promise for improving behavior.

CONCLUSIONS

Theory-based interventions seem to improve PA and diet behaviors in cancer survivors. Further studies, including thorough intervention descriptions, are needed to confirm these findings and identify the optimal features and content of lifestyle theory-based interventions for cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

This systematic review can contribute to the development of more effective interventions to promote long-term adherence to healthy lifestyle behaviors.

Falling short in bariatric surgery: An exploration of key barriers and motivators of attrition

BACKGROUND

In the United States, obesity-related diseases pose significant healthcare challenges, with bariatric surgery offering a potential solution. However, bariatric surgery completion rates, particularly among Black and Hispanic populations, remain low.

OBJECTIVE

This study applied the Theoretical Domains Framework (TDF) to explore behavioral factors influencing bariatric surgery program attrition among a majority Black participant population to inform interventions for improving attrition.

METHODS

We conducted semi-structured interviews with 40 surgical and non-surgical participants and conducted deductive content analysis informed by six TDF constructs to explore factors influencing bariatric surgery program attrition.

RESULTS

Participants' decision-making regarding bariatric surgery is influenced by behavioral factors, including knowledge, skills, social roles, beliefs about capabilities, optimism, and beliefs about consequences.

CONCLUSION

Understanding multifaceted factors influencing bariatric surgery attrition will inform the development of tailored interventions that address knowledge gaps, enhance skills, and consider social role conflicts to improve patient engagement and decision-making in managing obesity, especially for Black populations.

Experiences with home monitoring technology in older adults with traumatic brain injury: a qualitative study

BACKGROUND

Home monitoring systems utilising artificial intelligence hold promise for digitally enhanced healthcare in older adults. Their real-world use will depend on acceptability to the end user i.e. older adults and caregivers. We explored the experiences of adults over the age of 60 and their social and care networks with a home monitoring system installed on hospital discharge after sustaining a moderate/severe Traumatic Brain Injury (TBI), a growing public health concern.

METHODS

A qualitative descriptive approach was taken to explore experiential data from older adults and their caregivers as part of a feasibility study. Semi-structured interviews were conducted with 6 patients and 6 caregivers (N = 12) at 6-month study exit. Data were analysed using Framework analysis. Potential factors affecting acceptability and barriers and facilitators to the use of home monitoring in clinical care and research were examined.

RESULTS

Home monitoring was acceptable to older adults with TBI and their caregivers. Facilitators to the use of home monitoring were perceived need for greater support after hospital discharge, the absence of sound and video recording, and the peace of mind provided to care providers. Potential barriers to adoption were reliability, lack of confidence in technology and uncertainty at how data would be acted upon to improve safety at home.

CONCLUSIONS

Remote monitoring approaches are likely to be acceptable, especially if patients and caregivers see direct benefit to their care. We identified key barriers and facilitators to the use of home monitoring in older adults who had sustained TBI, which can inform the development of home monitoring for research and clinical use. For sustained use in this demographic the technology should be developed in conjunction with older adults and their social and care networks.

Improving hospice delirium guideline adoption through an understanding of barriers and facilitators: A mixed-methods study

OBJECTIVES

This study seeks to understand and address barriers to practitioners' optimal assessment and management of people with delirium in hospices.

METHODS

Retrospective clinical record review to identify areas of low concordance with guideline-adherent delirium care; Survey of healthcare practitioners to identify barriers and facilitators to optimal care; Qualitative interviews with health care practitioners to explore and develop strategies to address barriers or optimise facilitators; Meeting with senior clinical staff to refine identified strategies.

RESULTS

Eighty clinical records were reviewed. Elements of poor guideline concordance were identified. Delirium screening on admission was conducted for 61% of admissions. Non-pharmacological management was documented for 59% of those we identified as having delirium from the clinical records. Survey and interview data identified key barriers to delirium assessment as competing priorities, poor knowledge and skills and lack of environmental resources (staff and guidelines, environment). Consultation with staff resulted in strategies to address barriers and enhance facilitators including champions, educational meetings, audit and feedback, and environmental changes (including careful consideration of the staff skills mix on shift and tools to support non-pharmacological management).

CONCLUSIONS

We conducted a theoretically underpinned, internationally relevant study in a hospice in England, UK. Implementation of strategies should result in greater guideline-adherent delirium care. Further work should test this in practice and include both process and clinical outcomes (e.g., reduction in delirium days).

Moving beyond barriers: a mixed-method study to develop evidence-based strategies to improve implementation of PROMs in clinical oncology care

PURPOSE

This study aimed to identify feasible, evidence-based strategies to improve the use of Patient-reported outcome measures (PROMs) implemented in clinical oncology practice.

METHODS

A mixed-method study involving observations of consultations and semi-structured interviews with patients and healthcare professionals (HCPs) was conducted to identify facilitators and barriers for using PROMs; barriers and facilitators were structured following the Theoretical Domains Framework. For each barrier, evidence-based improvement strategies were selected using the Behaviour Change Techniques Taxonomy v1. Subsequently, improvement strategies were ranked on priority and feasibility by an expert panel of HCPs, information technology professionals, and PROMs implementation specialists, creating an implementation improvement strategy.

RESULTS

Ten consultations were observed and 14 interviews conducted. Barriers for implementation included that the electronic health record and PROMs did not align to the individual needs of end users, the HCPs' hesitance to advice patients about health-related quality-of-life issues, and a lack of consensus on which HCPs were responsible for discussing PROMs with patients. Forty-one improvement strategies were identified, of which 25 remained after ranking. These included: redesigning the PROMs dashboard by including patient management advice, enhancing patient support to complete PROMs, and clarifying HCPs' responsibilities for discussing PROMs. Strategies currently considered less feasible were: improving user-friendliness of the patient portal due to technical constraints, aligning PROMs assessment frequency with clinical courses, and using baseline PROMs for early identification of vulnerabilities and supportive care needs. These will be studied in future research.

CONCLUSION

Evidence-based improvement strategies to ensure lasting adoption of PROMs in clinical practice were identified.

Evaluating the impact of a standardised intervention for announcing decisions of withholding and withdrawing life-sustaining treatments on the stress of relatives in emergency departments (DISCUSS): protocol for a stepped-wedge randomised controlled trial

INTRODUCTION

The decisions of withholding or withdrawing life-sustaining treatments are difficult to make in the context of emergency departments (EDs) because most patients are unable to communicate. Relatives are thus asked to participate in the decision-making process, although they are unprepared to face such situations. We therefore aimed to develop a standardised intervention for announcing decisions of withholding or withdrawing life-sustaining treatments in EDs and assess the efficacy of the intervention on the stress of relatives.

METHODS AND ANALYSIS

The DISCUSS trial is a multicentre stepped-wedge cluster randomised study and will be conducted at nine EDs in France. A standardised intervention based on human simulation will be codesigned with partner families and implemented at three levels: the relatives, the healthcare professionals (HCP) and the EDs. The intervention will be compared with a control based on treatment as usual. A total of 538 families are planned to be included: 269 in the intervention group and 269 in the control group. The primary endpoint will be the symptoms of post-traumatic stress disorder (PTSD) at 90 days. The secondary endpoints will be symptoms of PTSD at 7 and 30 days, diagnosis of PTSD at 90 days and anxiety and depression scores at 7, 30 and 90 days. Satisfaction regarding the training, the assertiveness in communication and real-life stress of HCPs will be measured at 90 days.

ETHICS AND DISSEMINATION

This study was approved by the ethics committee Est III from Nancy and the French national data protection authority. All relatives and HCPs will be informed regarding the study objectives and data confidentiality. Written informed consent will be obtained from participants, as required by French law for this study type. The results from this study will be disseminated at conferences and in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT06071078.

Understanding aberrant driving intentions based on the Theory of Planned Behavior: Literature review and Meta-Analysis

INTRODUCTION

Despite deployed efforts to establish strict road safety standards, human factors is still the leading cause of road crashes. To identify determinants of driver's behavior, TPB (Theory of Planned Behavior) is widely used as a prominent theory of behavior change. However, the existence of different aberrant driving behaviors (decision errors, recognition errors, violations, and physical condition related errors) and several studies using TPB to understand driving behavior, makes it important to conduct a literature review and a meta-analysis of existing studies to use their results in effective driving behavior change interventions.

METHOD

The selection process provided 125 relevant studies that were published between 1991 and 2022, and that used TPB for the understanding of aberrant driving behavior. Five fundamental research questions were defined to identify information to be discovered from the literature review and from the meta-analysis.

RESULTS

In addition to the standard TPB constructs (attitudes, subjective norms, and perceived behavioral control), past behavior, moral norms, and descriptive norms were used in studies for a more comprehensive understanding of aberrant driving intention. This analysis demonstrated a significant correlation between aberrant driving intentions and past behavior. Also, moral norms construct was correlated with violations and recognition errors, whereas descriptive norms construct was correlated just with recognition errors.

CONCLUSIONS

The results of this study highlight the strength of TPB in the prediction of aberrant driving intention and its potential effectiveness to guide interventions aimed at changing aberrant driving behaviors. The study contributes to the comprehension of the relevant psychological factors influencing the engagement of drivers in each category of aberrant driving behaviors.

PRACTICAL APPLICATIONS

Researchers can use the results of this study to select the relevant psychological factors adapted to their interventions of driving behavior change. The results of the meta-analysis can also be used in the prediction of driver's intentions.

Establishing enablers and barriers to implementing the HIRAID® emergency nursing framework in rural emergency departments

BACKGROUND

Rural Australia has large geographic distances between emergency departments with variability of services and medical support. Emergency nurses must be appropriately skilled to assess and manage unpredictable and diverse presentations. HIRAID® is an evidence-based framework to support emergency nurses in assessment and care delivery. To inform implementation, the study aimed to identify the enablers and barriers to introducing HIRAID® in practice.

METHODS

This embedded mixed methods study was conducted in 11 rural, regional emergency departments in Southern New South Wales, Australia. Respondents completed a 22-item survey, indicating their level of agreement on statements related to practice change, free text responses were optional. Quantitative data were analysed using descriptive statistics and qualitative data using content analysis. Results were identified as barriers or enablers, then integrated and mapped to the Theoretical Domains Framework.

RESULTS

The survey was completed by 102 (54 %) nurses. Two enablers and four barriers to implementation were identified and mapped to 10 Theoretical Domains Framework domains. Key barriers were workplace limitations, such as time and resources, and knowledge of the HIRAID® intervention.

CONCLUSION

Barriers varied between facilities related to adequate support to implement and the impact on patient care. The results will inform a strategy to implement HIRAID®.

The unmet mental health needs of adolescents with HIV in eastern Tanzania: Experiences of healthcare providers, adolescents, and caregivers

Adolescents with Human Immunodeficiency Virus (HIV) are at greater risk for mental health problems than their HIV-negative counterparts. However, there is a dearth of evidence on the need for mental health services, including interventions for depression in adolescents with HIV (AWHIV), in most low- and middle-income countries (LMICs). This study's objective was to explore the unmet mental health needs of AWHIV to inform the development and implementation of a psychological intervention for depression in AWHIV in Dar es Salaam, Tanzania. A descriptive phenomenological qualitative study design was used. Consultative meetings with providers and 45 in-depth interviews were conducted with AWHIV, caregivers, and healthcare providers (HCPs) to explore their experiences and unmet mental health needs for AWHIV. Data from the consultative meetings were triangulated to validate the obtained information with those from interviews. Data were organized and managed with the aid of NVIvo-11. The thematic analysis framework guided data analysis. Five major themes emerged: Experience of complex symptoms, unmet need for services, impact of the unmet needs, ways utilized in managing symptoms, and preferred intervention. Complex depressive symptoms expressed as physical, behavioral, or somatic complaints adversely affected ART adherence and academic performance, led to substance use, and compromised overall quality of life in AWHIV. HIV-Care and Treatment Centers (HIV-CTCs) did not conduct formal mental health screenings. Instead, caregivers and HCPs addressed the symptoms of mental health problems with death threats and corporal punishments. No evidence-based depression interventions existed in HIV-CTCs for observed symptoms. This study reports on unmet mental health needs with a clear impact on the lives of AWHIV, which may have significant implications for treatment adherence. There is an urgent need to develop and implement effective and scalable interventions to address these mental health needs.

Leveraging implementation science theories to develop and expand the use of a penicillin allergy de-labeling intervention

BACKGROUND

Penicillin allergy is the most frequently reported drug allergy, yet most patients can tolerate the drug if challenged. Despite this discrepancy, large scale penicillin allergy de-labeling interventions have not been widely implemented in many health care systems. The application of a multi-method implementation science approach can provide key tools to study this evidence to practice gap and provide insight to successfully operationalize penicillin allergy evaluation in real-world clinical settings.

METHODS

We followed a four-step process that leverages qualitative analysis to design evidence-based, actionable strategies to develop an intervention. First, we specified the clinician-perceived barriers to penicillin allergy de-labeling (intervention targets). We then mapped intervention targets onto Theoretical Domains Framework (domains and constructs) and found the root causes of behavior. Next, we linked root causes of behavior with intervention functions (BCW). In the final step, we synthesized participants' suggestions for process improvement with implementation strategies aligning with the intervention functions.

RESULTS

Evidence-based strategies such as focused education and training in penicillin allergy evaluation can address knowledge and confidence barriers reported by frontline clinicians. Other key strategies involve developing a system of champions, improving communications systems, and restructuring the healthcare team. Implementation mapping can provide a powerful multi-method framework to study, design, and customize intervention strategies.

CONCLUSION

Empowering clinicians beyond allergy specialists to conduct penicillin allergy assessments requires designing new workflows and systems and providing additional knowledge to those clinicians.

Promotion of legume intake-Israeli dietitians' knowledge, beliefs and practices

BACKGROUND

The health and environmental benefits of legume consumption are reflected in dietary guidelines worldwide. However, legume intake fails to meet recommendations. Dietitians' legume counseling practices can impact consumption patterns. This cross-sectional study assessed Israeli dietitians' knowledge, attitudes, perceptions and practices regarding legume counseling and identified pertinent barriers and facilitators.

METHODS

An electronic survey among Israeli dietitians (n = 309) was performed. Multivariable logistic regression assessed associations between recommending legumes with participants' socio-demographic and professional characteristics, knowledge, perceptions, attitudes toward legume counseling and personal legume intake.

RESULTS

Almost half (47.4%) of the participants recommended that 76% or more of their patients increase legume intake. Factors that were associated with recommending legumes were perceptions of fewer barriers to consumption [adjusted OR (aOR) 1.92 (95% CI 1.24-2.96)] and positive attitudes toward legume counseling pertaining to its importance [aOR 1.95 (95% CI 1.12-3.4)]. Negatively associated factors were a low level of personal legume consumption [aOR 0.38 (95% CI 0.15-0.94)] and working in hospitals [aOR 0.43 (95% CI 0.19-0.98)].

CONCLUSIONS

Israeli dietitians' recommendations for legume consumption were well below current guidelines. These findings indicate the need for a tailored intervention for nutrition professionals to increase the frequency of legume counseling and overall consumption.

Theoretical Domains Framework: A Bibliometric and Visualization Analysis from 2005-2023

Background

The Theoretical Domains Framework (TDF) is among the most extensively utilised foundational frameworks in implementation science. It was developed from 33 psychological theories, with the latest version identifying 14 domains encompassing 84 theoretical constructs. These domains and constructs capture the complexity of factors that affect behaviours, making the framework a valuable tool for designing and implementing interventions within health and social care settings.

Objective

To summarise the development, hot topics, and future trends in TDF-related research and provide implementation practitioners with more information on the application of TDF.

Methods

We used TDF as the topic and searched the ISI Web of Science Core Collection, identifying 1382 relevant publications. We used analytical tools such as Excel, Tableau, VOSviewer, and Citespace to conduct a bibliometric analysis of the relevant publication.

Results

We identified the United Kingdom as the primary contributor, with University College London as the key institution. Susan Michie ranked highest in total citations. The analysis highlighted cancer and stroke as primary clinic medicine-related topics using TDF. Emerging themes encompass abuse, violence, maternal health, antenatal care, patient involvement, and trauma-informed care et al. "Nurse" and "qualitative research" emerged as recent and enduring hotspots, possibly indicating future research trends.

Conclusion

This article represents the first attempt to summarise the TDF using bibliometric analysis. We suggest this method can be used to analyse other theoretical frameworks in scientific implementation of its objectivity and quantifiability. Overall, the application scope of TDF is shifting from public health towards more specialised clinical directions, although its application in the field of public health is continuously expanding. In the future, the number of users of TDF is also expected to expand from implementation scientists to professional technical personnel.

Expert consensus on multilevel implementation hypotheses to promote the uptake of youth care guidelines: a Delphi study

BACKGROUND

The implementation of youth care guidelines remains a complex process. Several evidence-based frameworks aid the identification and specification of implementation determinants and strategies. However, the influence of specific strategies on certain determinants remains unclear. Therefore, we need to clarify which active ingredients of strategies, known as behaviour change techniques (BCTs), elicit behaviour change and improve implementation outcomes. With this knowledge, we are able to formulate evidence-based implementation hypotheses. An implementation hypothesis details how determinants and in turn, implementation outcomes might be influenced by specific implementation strategies and their BCTs. We aimed to identify (1) determinants relevant to the implementation of youth care guidelines and (2) feasible and potentially effective implementation hypotheses.

METHODS

A four-round online modified Delphi study was conducted. In the first round, experts rated the implementation determinants based on their relevance. Next, experts formulated implementation hypotheses by connecting BCTs and implementation strategies to determinants and were asked to provide a rationale for their choices. In round three, the experts reconsidered and finalised their hypotheses based on an anonymous overview of all formulated hypotheses, including rationales. Finally, the experts rated the implementation hypotheses based on their potential effectiveness and feasibility.

RESULTS

Fourteen experts completed the first, second, and third rounds, with 11 completed the final round. Guideline promotion, mandatory education, presence of an implementation leader, poor management support, knowledge regarding guideline use, and a lack of communication skills were reported as most relevant determinants. In total, 46 hypotheses were formulated, ranging from 6 to 9 per determinant. For each determinant, we provide an overview of the implementation hypotheses that were most commonly deemed feasible and potentially effective.

CONCLUSION

This study offers valuable insights into youth care guideline implementation by systematically identifying relevant determinants and formulating hypotheses based on expert input. Determinants related to engagement and to knowledge and skills were found to be relevant to youth care guideline implementation. This study offers a set of hypotheses that could help organisations, policymakers, and professionals guide the implementation process of youth care guidelines to ultimately improve implementation outcomes. The effectiveness of these hypotheses in practice remains to be assessed.

Development of an implementation strategy for routine collection of generic patient reported outcome measures: a qualitative study in multidisciplinary community rehabilitation

PURPOSE

To explore staff perceptions of barriers and enablers towards implementing the EQ-5D-5L in community rehabilitation, and develop a theory-informed implementation approach for routine administration of generic patient-reported outcome measures (PROMs) using implementation science frameworks.

MATERIALS AND METHODS

A qualitative study was conducted at three sites. Multidisciplinary rehabilitation staff completed individual semi-structured interviews, which were transcribed and coded against the Theoretical Domains Framework (TDF). We identified and selected potentially effective behaviour change techniques using the Behavior Change Wheel. Hypothetical strategies were operationalised.

RESULTS

Twenty-one interviews were conducted, and four themes emerged: (1) The Impact of PROMs on patient centered-care; (2) Considerations for validity of PROMs; (3) Service-level impact of embedding PROMs; (4) Practical issues of embedding PROMs within the service. Barriers and enablers were mapped to seven of the TDF domains; relating most to clinicians' "belief about consequences", "reinforcement", and "environmental context and resources". Five hypothetical strategies were developed to overcome identified barriers and strengthen enablers. Key behaviour change techniques underpinning the strategies include: restructuring the physical environment, incentivisation, persuasion and education, enablement, and, social support.

CONCLUSIONS

Our implementation approach highlights the importance of automating processes, engaging site champions, routinely reporting, and using PROM data to inform service provision.

Development of a Behavior-Change Intervention toward Benzodiazepine Deprescribing in Older Adults Living in Nursing Homes

OBJECTIVE

We aimed to develop a context-specific intervention toward benzodiazepine deprescribing in nursing homes (NHs), with insights from behavior-change theories and involvement of stakeholders.

DESIGN

Selection of behavior change techniques (BCTs), through online survey and group discussion, followed by operationalization of these BCTs into intervention components.

SETTING AND PARTICIPANTS

The intervention was developed for Belgian NHs, involving various stakeholders: health care professionals (HCPs), NH administrators, and policy makers.

METHODS

Using the Theory and Techniques Tool, we preselected the BCTs linked to one of the 9 Theoretical Domain Framework domains identified as being the main barriers for benzodiazepine deprescribing in Belgian NHs. These were then presented to stakeholders. Based on the APEASE (Acceptability, Practicability, Effectiveness, Affordability, Side-effects, and Ethics) criteria, participants ranked BCTs through an online survey, and then performed final selection during a group discussion. Selected BCTs were operationalized into intervention components, with specific contents and methods of delivery validated by stakeholders.

RESULTS

Thirty-seven potential BCTs were identified. Eighteen stakeholders participated in the survey, and 7 in the group discussion. This led to the final inclusion of 9 BCTs: instruction on how to perform the behavior, information about health consequences, pros and cons, problem solving, goal setting (behavior), social comparison, restructuring physical environment, restructuring social environment, and graded tasks. These BCTs were operationalized into a 6-component intervention: process and goal setting, HCP education, physical environment adaptations, audit and feedback, NH residents' and relatives' increased awareness, and multidisciplinary work.

CONCLUSION AND IMPLICATIONS

Use of a theory-based approach toward intervention development has the potential to improve the probability of its feasibility and effectiveness in tackling barriers to benzodiazepine deprescribing. By doing so, we have developed a multifaceted approach with actions taken at the patient, HCP, and NH levels. Our novel 6-component intervention will be evaluated in a pilot cluster-randomized controlled trial to assess its feasibility.

Bridging the Gap between Intuition and Theory: A Comparison of Different Approaches to Implementation Strategy Development for Improving Lynch Syndrome Detection

INTRODUCTION

Despite growing calls for the explicit application of theory when designing behaviour change interventions, limited empirical evidence exists regarding the effectiveness of these methods compared to non-theoretical approaches. A cluster randomized controlled trial (Hide and Seek Project - HaSP) tested two implementation approaches for improving hereditary cancer referral practices with one key distinction: implementation strategies were designed based explicitly on psychological theory or based on stakeholder intuition. This study presents the detailed methods and resources used to facilitate this comparison, whilst examining the strategies generated through both approaches.

METHODS

Across seven Australian hospitals, clinical stakeholders attended focus groups to co-design site-specific strategies for improving Lynch syndrome referral. Co-design methods differed according to trial arm. Implementation strategy content was examined, with intuitively derived strategies retrospectively coded to determine theoretical alignment.

RESULTS

Fifty-one strategies were proposed across all sites (theory-based arm = 32, intuition-based arm = 19). Overall, nine behaviour change technique (BCT) categories were used on 77 occasions. In the theory-based trial arm, eight BCT categories were identified on 53 occasions; and five BCT categories on 24 occasions in the intuition-based arm. BCT categories were largely similar across both arms. After retrospectively coding intuitively derived strategies, 42% contained mechanistic links, thereby demonstrating theoretical alignment.

CONCLUSION

Methods facilitated robust comparison of theoretical and intuitive approaches to implementation strategy design. Recognizing the known benefits of theory for enhancing scientific learning, applying these methods on a larger scale may provide definitive evidence about the comparative effectiveness of theoretical approaches.

Digital screening for mental health in pregnancy and postpartum: A systematic review

PURPOSE

This systematic review aimed to determine if digital screening for mental health in pregnancy and postpartum is acceptable, feasible and more effective than standard care (paper-and pen-based screening or no screening). The second aim was to identify barriers and enablers to implementing digital screening in pregnancy and postpartum.

METHOD

OVID MEDLINE, PsycINFO, SCOPUS, CINAHL, Embase, Web of Science, Joanna Briggs Database and All EMB reviews incorporating Cochrane Database of Systematic Reviews (OVID) were systematically searched for articles that evaluated digital screening for mental health in pregnancy and postpartum between 2000 and 2021. Qualitative articles were deductively mapped to the Theoretical Domains Framework (TDF).

RESULTS

A total of 34 articles were included in the analysis, including qualitative, quantitative and mixed-methods studies. Digital screening was deemed acceptable, feasible and effective. TDF domains for common barriers included environmental context and resources, skills, social/professional role and identity and beliefs about consequences. TDF domains for common enablers included knowledge, social influences, emotion and behavioural regulation.

CONCLUSION

When planning to implement digital screening, consideration should be made to have adequate training, education and manageable workload for healthcare professionals (HCP's). Organisational resources and support are important, as well as the choice of the appropriate digital screening assessment and application setting for women. Theory-informed recommendations are provided for both healthcare professionals and women to inform future clinical practice.

Understanding barriers and facilitators to integrated HIV and hypertension care in South Africa

BACKGROUND

The burden of hypertension among people with HIV is high, particularly in low-and middle-income countries, yet gaps in hypertension screening and care in these settings persist. This study aimed to identify facilitators of and barriers to hypertension screening, treatment, and management among people with HIV in primary care clinics in Johannesburg, South Africa. Additionally, different stakeholder groups were included to identify discordant perceptions.

METHODS

Using a cross-sectional study design, data were collected via interviews (n = 53) with people with HIV and hypertension and clinic managers and focus group discussions (n = 9) with clinic staff. A qualitative framework analysis approach guided by COM-B and the Theoretical Domains Framework were used to identify and compare determinants of hypertension care across stakeholder groups.

RESULTS

Data from clinic staff and managers generated three themes characterizing facilitators of and barriers to the adoption and implementation of hypertension screening and treatment: 1) clinics have limited structural and operational capacity to support the implementation of integrated care models, 2) education and training on chronic care guidelines is inconsistent and often lacking across clinics, and 3) clinicians have the goal of enhancing chronic care within their clinics but first need to advocate for health system characteristics that will sustainably support integrated care. Patient data generated three themes characterizing existing facilitators of and barriers to clinic attendance and chronic disease self-management: 1) the threat of hypertension-related morbidity and mortality as a motivator for lifestyle change, 2) the emotional toll of clinic's logistical, staff, and resource challenges, and 3) hypertension self-management as a patchwork of informational and support sources. The main barriers to hypertension screening, treatment, and management were related to environmental resources and context (i.e., lack of enabling resources and siloed flow of clinic operations) and patients' knowledge and emotions (i.e., lack of awareness about hypertension risk, fear, and frustration). Clinical actors and patients differed in perceived need to prioritize HIV versus hypertension care.

CONCLUSIONS

The convergence of multi-stakeholder data highlight key areas for improvement, where tailored implementation strategies targeting motivations of clinic staff and capacity of patients may address challenges to hypertension screening, treatment, and management recognized across groups.

Telemedicine in primary care of older adults: a qualitative study

BACKGROUND

The COVID-19 pandemic changed the healthcare system, leading to the rapid evolution and implementation of telemedicine (TM). TM has the potential to improve the quality of primary health care and increase accessibility for the population. However, its use may represent challenges for older people, as they may have distinct needs from the general population due to age-related changes in perceptual, motor, and cognitive capacities. We, thus, aimed to identify potential facilitators and barriers to TM use in primary care for older adults and develop recommendations accordingly.

METHODS

We conducted a qualitative study to explore the challenges associated with TM use among older adults and healthcare professionals (HCPs) in primary care practice. Interviews were conducted with 29 older adults, and three focus groups involving HCPs from four McGill family medicine sites were organized. Employing a hybrid codebook thematic analysis, guided by the Consolidated Framework for Implementation Research (CFIR), we identified facilitators and barriers affecting the optimal use of TM by older adults and HCPs. We synthesized the results from semi-structured interviews and focus groups. These findings were then presented during a deliberative dialogue with eight participants, including family physicians, nurses, a social worker, and a government-level TM expert, to validate our results. The purpose was to gather feedback, identify and refine actionable recommendations. Subsequently, we utilized a thematic analysis using the same codebook to synthesize findings from the deliberative dialogue.

RESULTS

Participants agreed that TM contributed to maintaining the continuity of care and was particularly convenient when there was an existing or established patient-physician relationship or for addressing minor health issues. TM was found to be beneficial for people with limited mobility, reducing their exposure to potentially high-risk environments. However, participants expressed concerns about the lack of visual contact, causing essential details to be overlooked. Additionally, issues related to miscommunication due to language or hearing barriers were identified. HCPs perceived that most older adults did not consider phone consultations a medical act. Participants were open to a hybrid approach, combining in-person consultations and TM, based on their specific health conditions. Building upon these results, we formulated seven key recommendations.

CONCLUSIONS

Both older adults and HCPs consider TM a good alternative for accessing healthcare services. To improve the effective use of TM, it's crucial to advocate for a hybrid approach that integrates both in-person and virtual methods. This approach should actively encourage and support individuals in becoming familiar with technological tools.

Exploring barriers and facilitators to the adoption of regular exercise practice in patients at risk of a recurrence of low back pain (MyBack project): a qualitative study

PURPOSE

This study aimed to explore potential barriers and facilitators to the adoption of regular exercise practice in patients at risk of a recurrence of low back pain (LBP).

MATERIALS AND METHODS

Eleven patients, who recovered from a previous episode of LBP, participated in two focus groups. The semi-structured interview schedule was informed by the Behaviour Change Wheel and the Theoretical Domains Framework. Focus groups were held through videoconference, audio and video recorded and transcribed verbatim. A deductive content analysis was performed by two researchers independently.

RESULTS

Eighteen barriers and 19 facilitators were identified. The most common barriers included "lack of knowledge on how to manage a recurrence of LBP," "lack of behavioural regulation strategies and having other priorities" and "lack of self-efficacy/confidence to practice exercise autonomously and deal with a new episode of LBP." "Knowledge on exercise and recurrences," "regular exercise habits," "having specific behavioural regulation strategies," "exercise practice with others," "willingness to practice exercise and considering it a priority," and "presence of positive emotions related with exercise practice" were the most common facilitators.

CONCLUSIONS

These findings will inform the development of a behaviour change-informed exercise intervention to promote regular exercise practice among patients at risk of a recurrence of LBP.

Optimizing implementation: elucidating the role of behavior change techniques and corresponding strategies on determinants and implementation performance: a cross-sectional study

INTRODUCTION

Behavior change techniques (BCTs) are considered as active components of implementation strategies, influencing determinants and, ultimately, implementation performance. In our previous Delphi study, experts formulated 'implementation hypotheses', detailing how specific combinations of BCTs and strategies (referred to as BCT-strategy combinations) might influence determinants and guideline implementation within youth care. For example, educational meetings providing instructions on guideline use were hypothesized to enhance practitioners' knowledge and, consequently, guideline implementation. However, these hypotheses have not been verified in practice yet.

METHOD

We conducted a cross-sectional study involving practitioners and management professionals from youth (health)care organizations. Using questionnaires, we obtained data on the presence of BCT-strategy combinations and their perceived influence on determinants and implementation performance. Chi-squared tests and regression analyses were employed to determine the influence of specific BCT-strategy combinations on determinants and implementation performance.

RESULTS

Our analyses included data from 104 practitioners and 34 management professionals. Most of the management professionals indicated that the BCT-strategy combinations positively influenced or had the potential to influence their implementation performance. At the practitioner level, half of the combinations were perceived to have a positive influence on determinants and implementation performance. Furthermore, practitioners who reported the absence of BCT-strategy combinations were more skeptical about their potential influence on determinants and implementation performance.

CONCLUSION

Several BCT-strategy combinations were perceived to improve or potentially improve implementation performance of both practitioners and management professionals. In the development and evaluation of implementation efforts, we advocate for clearly describing the implementation effort's objective and using frameworks that detail the BCTs inducing behavior change, the strategy employed, and the processes driving the observed changes. Understanding these interconnected processes is important in designing targeted, evidence-based behavior change interventions. This understanding optimizes resource allocation and contributes to the overall success of implementation efforts in youth care.

Using an intersectionality lens to explore barriers and enablers to hepatitis C point-of-care testing: a qualitative study among people who inject drugs and service providers

BACKGROUND

Hepatitis C virus (HCV) infection is a significant global health burden, particularly among people who inject drugs. Rapid point-of-care HCV testing has emerged as a promising approach to improve HCV detection and linkage to care in harm reduction organizations such as needle and syringe programs. The objective of this study was to use an intersectionality lens to explore the barriers and enablers to point-of-care HCV testing in a needle and syringe program.

METHODS

A qualitative study was conducted using semi-structured interviews with clients (people who inject drugs) and service providers in a large community organization focused on the prevention of sexually transmitted and blood borne infections and harm reduction in Montreal, Canada. An intersectionality lens was used alongside the Theoretical Domains Framework to guide the formulation of research questions as well as data collection, analysis, and interpretation.

RESULTS

We interviewed 27 participants (15 clients, 12 providers). For clients, four themes emerged: (1) understanding and perceptions of HCV testing, (2) the role of an accessible and inclusive environment, (3) the interplay of emotions and motivations in decision-making, and (4) the impact of intersectional stigma related to HCV, behaviors, and identities. For providers, five themes emerged: (1) knowledge, skills, and confidence for HCV testing, (2) professional roles and their intersection with identity and lived experience, (3) resources and integration of services, (4) social and emotional factors, and (5) behavioral regulation and incentives for HCV testing. Intersectional stigma amplified access, emotional and informational barriers to HCV care for clients. In contrast, identity and lived experience acted as powerful enablers for providers in the provision of HCV care.

CONCLUSION

The application of an intersectionality lens provides a nuanced understanding of multilevel barriers and enablers to point-of-care HCV testing. Findings underscore the need for tailored strategies that address stigma, improve provider roles and communication, and foster an inclusive environment for equitable HCV care. Using an intersectionality lens in implementation research can offer valuable insights, guiding the design of equity-focused implementation strategies.

Investigating the acceptability of modified constraint-induced movement therapy among stroke survivors and carers: a qualitative study

PURPOSE

To investigate the acceptability of modified constraint-induced movement therapy (mCIMT) among stroke survivors and carers within an early-supported discharge (ESD) service, and to inform further adaptations of the program to enhance acceptability.

METHODS

Qualitative study within a mixed methods process evaluation of mCIMT implementation. Semi-structured interviews were analysed using reflexive thematic analysis and mapped to the Capability, Opportunity, Motivation- Behaviour (COM-B) model.

RESULTS

Fifteen stroke survivors and ten carers participated. Five themes were generated and mapped to the COM-B. Participants attributed functional improvements to the program whilst also encountering several challenges with returning home after stroke (Capability- physical); the importance of education (Capability- psychological); the benefits afforded by the structured nature of the program (Opportunity- physical); the challenges for carers to support mCIMT programs whilst navigating new relationship roles (Opportunity- social); the desire to improve (Motivation- automatic); and the influence each of the mCIMT program's components had in facilitating long term upper limb use (Motivation- reflective).

CONCLUSION

mCIMT was an acceptable intervention for stroke survivors and carers within the ESD service, offering considerable benefits compared to other therapies. The findings suggest that multifaceted education strategies could increase stroke survivor preparedness. Extending the mCIMT program duration may maximise functional improvements.

Enablers and barriers to implementing an interdisciplinary experiential learning program for university students in a Canadian rehabilitation centre

Objective

This qualitative study aims to identify a comprehensive set of enablers and barriers to implementing an interdisciplinary experiential learning program for university students at a Canadian rehabilitation centre.

Methods

A researcher conducted one-on-one semi-structured interviews with individuals from four key stakeholder groups (i.e., rehabilitation centre leadership, clinicians, university clinical coordinators, and health and rehabilitation students). Interviews and data analysis followed the Theoretical Domains Framework (TDF), which is designed to identify possible cognitive, affective, social, and environmental influences on program implementation. Interviews were transcribed verbatim, and two researchers coded data independently to identify the major themes of enablers and barriers to implementing an interdisciplinary experiential learning approach to rehabilitation care.

Results

From a total of 12 interviews, domains of the TDF were identified to represent overarching themes, which were (1) enablers (i.e., reinforcement, beliefs and consequences, optimism, professional identity, knowledge, and skills), (2) barriers (i.e., environment/resources and beliefs and capabilities), and (3) program development (i.e., goals and evaluation that was not previously a TDF domain). A list of recommendations for implementing an interdisciplinary experiential learning program was created that represented qualitative data from each stakeholder group.

Conclusion

This study provides insight into the potential enablers and barriers to developing an interdisciplinary experiential learning program for university students within rehabilitation centres. This type of program could enhance educational curriculums, student and clinical experiences, and patient outcomes. In this study, the findings inform recommendations for developing an interdisciplinary program in teaching hospitals and explore their potential impact. Future research and pilot studies must be conducted to fully understand the effects of implementing an interdisciplinary experiential learning approach within rehabilitation centres.

Barriers and Facilitators to Participation in Vigorous Lifestyle Physical Activity in Adults Aged 55-75 Years: A Scoping Review

Despite the well-known benefits of physical activity, less than half of adults aged 55-75 years participate in sufficient physical activity. Short bouts of vigorous intermittent lifestyle physical activity (VILPA) accumulated throughout the day can contribute toward the recommended volume of physical activity. A rich characterization of the barriers and facilitators to participation in VILPA is needed to develop targeted interventions. This scoping review aimed to identify barriers and facilitators to participation in different components of VILPA in adults aged 55-75 years, and to map barriers and facilitators to the Theoretical Domains Framework. Within the 18 eligible studies, the most prevalent barriers were related to a person's skills, environmental context, and social influences. Most facilitators were related to a person's goals, social influences, and environmental context. Interventions to promote VILPA should test the effectiveness of behavioral change measures related to the unique barriers and facilitators in this age group.

Effectiveness of early diagnosis of cerebral palsy guideline implementation: a systematic review

INTRODUCTION

Tailored implementation interventions are required to overcome the diagnostic research-practice gap for cerebral palsy (CP). Evaluating the impact of interventions on patient outcomes is a priority. This review aimed to summarize the established evidence for the effectiveness of guideline implementations in lowering the age of CP diagnosis.

EVIDENCE ACQUISITION

A systematic review was conducted according to PRISMA. CINAHL, Embase, PubMed and MEDLINE were searched (2017-October 2022). Inclusion criteria were studies that evaluated effect of CP guideline interventions on health professional behaviour or patient outcomes. GRADE was used to determine quality. Studies were coded for use of theory (Theory Coding Scheme). Meta-analysis was performed and a standardized metric used to summarize statistics of intervention effect estimates.

EVIDENCE SYNTHESIS

Of (N.=249) records screened, (N.=7) studies met inclusion, comprising interventions following infants less than 2 years of age with CP risk factors (N.=6280). Guideline feasibility in clinical practice was established through health professional adherence and patient satisfaction. Efficacy of patient outcome of CP diagnosis by 12 months of age was established in all studies. Weighted averages were: (1) high-risk of CP (N.=2) 4.2 months and (2) CP diagnosis (N.=5) at 11.6 months. Meta-analysis of (N.=2) studies found a large, pooled effect size Z = 3.00 (P=0.003) favoring implementation interventions lowering age of diagnosis by 7.50 months, however study heterogeneity was high. A paucity of theoretical frameworks were identified in this review.

CONCLUSIONS

Multifaceted interventions to implement the early diagnosis of CP guideline are effective in improving patient outcomes by lowering the age of CP diagnosis in high-risk infant follow-up clinics. Further targeted health professional interventions including low-risk infant populations are warranted.

Promoting planting in front gardens: a systematic approach to intervention development

Planting in front gardens is associated with a range of human and environmental health benefits. Effective interventions aimed at cultivating this practice are, however, hampered by the paucity of theory- and evidence-based behavioural research in this context. This study aims to systematically determine a set of behaviour change interventions likely to be effective at promoting planting in front gardens amongst UK householders. The Behaviour Change Wheel framework was applied. Behavioural systems mapping was used to identify community actors relevant to front gardening. Potential behavioural influences on householders' front gardening were identified using the Capability, Opportunity, Motivation, Behaviour model. Using peer-reviewed scientific findings as evidence, behavioural influences were systematically linked to potential intervention strategies, behaviour change techniques and real-world implementation options. Finally, intervention recommendations were refined through expert evaluations and local councillor and public stakeholder feedback, evaluating them against the Acceptability, Practicability, Effectiveness, Affordability, Side effects and Equity criteria in a UK implementation context. This study formulated 12 intervention recommendations, implementable at a community level, to promote front gardening. Stakeholder feedback revealed a preference for educational and supportive (social and practical) strategies (e.g., community gardening workshops, front gardening 'starter kits') over persuasive and motivational approaches (e.g., social marketing, motivational letters from the council to householders). Householders' front gardening behaviour is complex and influenced by the behaviour of many other community actors. It also needs to be understood as a step in a continuum of other behaviours (e.g., clearing land, gardening, waste disposal). This study demonstrates the application of behavioural science to an understudied implementation context, that is, front gardening promotion, drawing on a rigorous development process promoting a transparent approach to intervention design. Stakeholder consultation allowed relevance, feasibility and practical issues to be considered. These improve the likely effectiveness of interventions in practice. The next steps include evaluating the proposed interventions in practice.

Perspectives on low-value care and barriers to de-implementation among primary care physicians: a multinational survey

BACKGROUND

Healthcare costs are rising worldwide. At the same time, a considerable proportion of care does not benefit or may even be harmful to patients. We aimed to explore attitudes towards low-value care and identify the most important barriers to the de-implementation of low-value care use in primary care in high-income countries.

METHODS

Between May and June 2022, we email surveyed primary care physicians in six high-income countries (Austria, Finland, Greece, Italy, Japan, and Sweden). Physician respondents were eligible if they had worked in primary care during the previous 24 months. The survey included four sections with categorized questions on (1) background information, (2) familiarity with Choosing Wisely recommendations, (3) attitudes towards overdiagnosis and overtreatment, and (4) barriers to de-implementation, as well as a section with open-ended questions on interventions and possible facilitators for de-implementation. We used descriptive statistics to present the results.

RESULTS

Of the 16,935 primary care physicians, 1,731 answered (response rate 10.2%), 1,505 had worked in primary care practice in the last 24 months and were included in the analysis. Of the respondents, 53% had read Choosing Wisely recommendations. Of the respondents, 52% perceived overdiagnosis and 50% overtreatment as at least a problem to some extent in their own practice. Corresponding figures were 85% and 81% when they were asked regarding their country's healthcare. Respondents considered patient expectations (85% answered either moderate or major importance), patient's requests for treatments and tests (83%), fear of medical error (81%), workload/lack of time (81%), and fear of underdiagnosis or undertreatment (79%) as the most important barriers for de-implementation. Attitudes and perceptions of barriers differed significantly between countries.

CONCLUSIONS

More than 80% of primary care physicians consider overtreatment and overdiagnosis as a problem in their country's healthcare but fewer (around 50%) in their own practice. Lack of time, fear of error, and patient pressures are common barriers to de-implementation in high-income countries and should be acknowledged when planning future healthcare. Due to the wide variety of barriers to de-implementation and differences in their importance in different contexts, understanding local barriers is crucial when planning de-implementation strategies.

Perceptions and behaviors of healthcare providers towards rehabilitation support to children with severe malaria-related disability in Ethiopia: A qualitative descriptive study using the Theoretical Domains Framework

INTRODUCTION

Severe malaria often results in childhood disability. The prevalence of disability related to severe malaria is significant and is estimated to affect up to 53% of severe malaria survivors. In contrast, information is sparse about how healthcare providers in Africa think about or provide rehabilitation support in acute and post-acute phases respectively. Understanding the perceptions and behaviors of healthcare providers treating malaria could help inform malaria-related disability research, policy, and practice, aimed at the providers themselves. This study explored the perceptions and behaviors of healthcare providers towards rehabilitation for children with severe malaria-related disability. The Theoretical Domains Framework was used to describe the findings relative to wider literature on health provider behavior change.

METHODS

A qualitative descriptive approach was used to interview thirteen healthcare providers recruited purposively based on their clinical professions, roles, and settings. Data were analyzed using directed content analysis. We decided on the most prominent theoretical domains considering the frequency of specific perceptions and behaviors across the participants, the frequency of perceptions and behaviors in each domain, and evidence of strong perceptions and behaviors.

RESULTS

Nine out of fourteen theoretical domains were identified. These domains were: Beliefs about consequences, environmental context and resources, goals, knowledge, skills, optimism, reinforcement, social influences, and social or professional role and identity. Healthcare providers' beliefs about their roles in screening for disability or referring to rehabilitation were less positive.

CONCLUSIONS

The findings of this study suggest the need for interventions to support healthcare providers in acute phases (prevention and control of severe malaria) and post-acute phases (disability screening, referral, and rehabilitation care). Recommended interventions should focus on developing clinical guidelines, training clinicians, addressing institutional factors, and modifying external social influences such as socio-cultural factors.

Optimizing Teamwork in the Operating Room: A Scoping Review of Actionable Teamwork Strategies

Suboptimal teamwork in the operating room (OR) is a contributing factor in a significant proportion of preventable complications for surgical patients. Specifying behaviour is fundamental to closing evidence-practice gaps in healthcare. Current teamwork interventions, however, have yet to be synthesized in this way. This scoping review aimed to identify actionable strategies for use during surgery by mapping the existing literature according to the Action, Actor, Context, Target, Time (AACTT) framework. The databases MEDLINE (Medical Literature Analysis and Retrieval System Online), Embase, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Education Resources Information Center (ERIC), Cochrane, Scopus, and PsycINFO were searched from inception to April 5, 2022. Screening and data extraction were conducted in duplicate by pairs of independent reviewers. The search identified 9,289 references after the removal of duplicates. Across 249 studies deemed eligible for inclusion, eight types of teamwork interventions could be mapped according to the AACTT framework: bundle/checklists, protocols, audit and feedback, clinical practice guidelines, environmental change, cognitive aid, education, and other), yet many were ambiguous regarding the actors and actions involved. The 101 included protocol interventions appeared to be among the most actionable for the OR based on the clear specification of ACCTT elements, and their effectiveness should be evaluated and compared in future work.

Feasible Peer-Mediated Intervention for Autistic Children Using Minimal Speech: A Qualitative Intervention Development Process

PURPOSE

Qualitative engagement with stakeholders in the development of interventions can provide insight into strategies to maximize feasibility in real-life settings. We engaged stakeholders (autistic adults, early childhood educators, early childhood sector leaders and policy influencers, parents of autistic children, and speech-language pathologists) to inform the development of an educator-led peer-mediated intervention (PMI) for autistic preschoolers who use minimal speech that is feasible to implement in inclusive early childhood education and care (ECEC) settings.

METHOD

A qualitative iterative intervention design process was utilized. Stakeholders (N = 15) attended an online workshop and completed a document review exploring the acceptability and feasibility of the proposed embedded PMI. A two-step analysis procedure using the Theoretical Domains Framework and template analysis was conducted to identify the barriers, enablers, and supports to the implementation of embedded PMI in early childhood settings.

RESULTS

While embedded PMI was unanimously acceptable to stakeholders, several participants expressed concerns regarding feasibility. Barriers to the successful integration and implementation of PMI in inclusive preschool contexts included access to skills, knowledge, and resources. Participants identified strategies to overcome modifiable barriers and to enhance the existing enablers. These strategies are reflected in the following themes: build on the familiar, build capacity in augmentative and alternative communication, adopt a whole center approach, adapt to meet the needs of the ECEC setting, and engage in proactive implementation.

CONCLUSION

To address barriers to the implementation of embedded PMI, action is needed at various levels: macro (national/policy), meso (organization/setting), and micro (individual).

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.25155770.

Multicomponent processes to identify and prioritise low-value care in hospital settings: a scoping review

OBJECTIVES

This scoping review mapped and synthesised original research that identified low-value care in hospital settings as part of multicomponent processes.

DESIGN

Scoping review.

DATA SOURCES

Electronic databases (EMBASE, PubMed, CINAHL, PsycINFO and Cochrane CENTRAL) and grey literature were last searched 11 July and 3 June 2022, respectively, with no language or date restrictions.

ELIGIBILITY CRITERIA

We included original research targeting the identification and prioritisation of low-value care as part of a multicomponent process in hospital settings.

DATA EXTRACTION AND SYNTHESIS

Screening was conducted in duplicate. Data were extracted by one of six authors and checked by another author. A framework synthesis was conducted using seven areas of focus for the review and an overuse framework.

RESULTS

Twenty-seven records were included (21 original studies, 4 abstracts and 2 reviews), originating from high-income countries. Benefit or value (11 records), risk or harm (10 records) were common concepts referred to in records that explicitly defined low-value care (25 records). Evidence of contextualisation including barriers and enablers of low-value care identification processes were identified (25 records). Common components of these processes included initial consensus, consultation, ranking exercise or list development (16 records), and reviews of evidence (16 records). Two records involved engagement of patients and three evaluated the outcomes of multicomponent processes. Five records referenced a theory, model or framework.

CONCLUSIONS

Gaps identified included applying systematic efforts to contextualise the identification of low-value care, involving people with lived experience of hospital care and initiatives in resource poor contexts. Insights were obtained regarding the theories, models and frameworks used to guide initiatives and ways in which the concept 'low-value care' had been used and reported. A priority for further research is evaluating the effect of initiatives that identify low-value care using contextualisation as part of multicomponent processes.

Effect of implementation strategies on the routine provision of antenatal care addressing smoking in pregnancy: study protocol for a non-randomised stepped-wedge cluster controlled trial

INTRODUCTION

Globally, guideline-recommended antenatal care for smoking cessation is not routinely delivered by antenatal care providers. Implementation strategies have been shown to improve the delivery of clinical practices across a variety of clinical services but there is an absence of evidence in applying such strategies to support improvements to antenatal care for smoking cessation in pregnancy. This study aims to determine the effectiveness and cost effectiveness of implementation strategies in increasing the routine provision of recommended antenatal care for smoking cessation in public maternity services.

METHODS AND ANALYSIS

A non-randomised stepped-wedge cluster-controlled trial will be conducted in maternity services across three health sectors in New South Wales, Australia. Implementation strategies including guidelines and procedures, reminders and prompts, leadership support, champions, training and monitoring and feedback will be delivered sequentially to each sector over 4 months. Primary outcome measures will be the proportion of: (1) pregnant women who report receiving a carbon monoxide breath test; (2) smokers or recent quitters who report receiving quit/relapse advice; and (3) smokers who report offer of help to quit smoking (Quitline referral or nicotine replacement therapy). Outcomes will be measured via cross-sectional telephone surveys with a random sample of women who attend antenatal appointments each week. Economic analyses will be undertaken to assess the cost effectiveness of the implementation intervention. Process measures including acceptability, adoption, fidelity and reach will be reported.

ETHICS AND DISSEMINATION

Ethics approval was obtained through the Hunter New England Human Research Ethics Committee (16/11/16/4.07; 16/10/19/5.15) and the Aboriginal Health and Medical Research Council (1236/16). Trial findings will be disseminated to health policy-makers and health services to inform best practice processes for effective guideline implementation. Findings will also be disseminated at scientific conferences and in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry-ACTRN12622001010785.

"I'm Torn": Qualitative Analysis of Dental Practitioner-Perceived Barriers, Facilitators, and Solutions to HPV Vaccine Promotion

The human papillomavirus (HPV) vaccine can prevent HPV-related oropharyngeal cancers. Dental practitioners are uniquely positioned to promote HPV vaccines during routine dental care but experience barriers to doing so. Qualitative interviews were conducted with dental practitioners to understand barriers and inform intervention strategies to promote HPV vaccines. Dental practitioners were invited to participate in phone interviews about knowledge, self-efficacy, and the fear of negative consequences related to HPV vaccine promotion as well as feedback on potential interventions to address these barriers. Interviews were audio recorded, transcribed, and analyzed using rapid qualitative analysis with a sort-and-sift matrix approach. Interviews were completed with 11 practitioners from six dental clinics (avg. 31 min). Though most thought HPV vaccination was important, they lacked detailed knowledge about when and to whom the vaccine should be recommended. This led to a hypothesized need for discussions of sexual history, feelings of limited self-efficacy to make the recommendation, and fear of patient concerns. Still, practitioners were supportive of additional training opportunities and provided input into specific interventions. The nuance of how these barriers were described by practitioners, as well as the possible solutions they identified, will help shape future interventions supporting HPV vaccine promotion in dental care.

Breaking Boundaries in Pneumonia Diagnostics: Transitioning from Tradition to Molecular Frontiers with Multiplex PCR

The advent of rapid molecular microbiology testing has revolutionized infectious disease diagnostics and is now impacting pneumonia diagnosis and management. Molecular platforms offer highly multiplexed assays for diverse viral and bacterial detection, alongside antimicrobial resistance markers, providing the potential to significantly shape patient care. Despite the superiority in sensitivity and speed, debates continue regarding the clinical role of multiplex molecular testing, notably in comparison to standard methods and distinguishing colonization from infection. Recent guidelines endorse molecular pneumonia panels for enhanced sensitivity and rapidity, but implementation requires addressing methodological differences and ensuring clinical relevance. Diagnostic stewardship should be leveraged to optimize pneumonia testing, emphasizing pre- and post-analytical strategies. Collaboration between clinical microbiologists and bedside providers is essential in developing implementation strategies to maximize the clinical utility of multiplex molecular diagnostics in pneumonia. This narrative review explores these multifaceted issues, examining the current evidence on the clinical performance of multiplex molecular assays in pneumonia, and reflects on lessons learned from previous microbiological advances. Additionally, given the complexity of pneumonia and the sensitivity of molecular diagnostics, diagnostic stewardship is discussed within the context of current literature, including implementation strategies that consider pre-analytical and post-analytical modifications to optimize the clinical utility of advanced technologies like multiplex PCR.

Dutch GPs' perspectives on addressing obesity: a qualitative study

BACKGROUND

Early diagnosis and treatment of obesity in primary care may help to tackle the obesity pandemic. Nonetheless, GPs frequently fail to address obesity and demonstrate limited adherence to guidelines.

AIM

To explore Dutch GPs' perspectives on addressing obesity regarding the following three target behaviours: discussing weight; diagnosing; and referring patients with obesity.

DESIGN & SETTING

A qualitative focus group study with Dutch GPs.

METHOD

Six focus groups were conducted with a purposive sample of 21 GPs. Thematic analysis was performed using deductive coding, according to the Theoretical Domains Framework (TDF).

RESULTS

For discussing weight, the main barriers identified were a presented complaint unrelated to obesity (environmental context and resources), concerns about a negative response from the patient (beliefs about consequences), and worries about obesity being a sensitive subject to discuss (emotions). A long-term trustworthy relationship (social influences) facilitated discussing weight. For diagnosing patients with obesity, the main barriers were related to resources; for example, lack of (appropriate) measuring equipment and time (environmental context and resources). For referring patients with obesity, the main barriers were no referral options nearby (environmental context and resources), and doubts about the positive effects of the referral on weight change (beliefs about consequences).

CONCLUSION

Different barriers for discussing weight, diagnosing, and referring patients with obesity were identified, underscoring the importance for tailored interventions to these specific behaviours. Improving knowledge and skills of GPs seems insufficient as this study showed that particular attention should be paid to establishing long-term relationships, addressing GPs' beliefs about consequences, and creating a supportive environment with sufficient time and resources.

Barriers and enablers to the implementation of patient-reported outcome and experience measures (PROMs/PREMs): protocol for an umbrella review

BACKGROUND

Patient-reported outcome and experience measures (PROMs and PREMs, respectively) are evidence-based, standardized questionnaires that can be used to capture patients' perspectives of their health and health care. While substantial investments have been made in the implementation of PROMs and PREMs, their use remains fragmented and limited in many settings. Analysis of multi-level barriers and enablers to the implementation of PROMs and PREMs has been hampered by the lack of use of state-of-the-art implementation science frameworks. This umbrella review aims to consolidate available evidence from existing quantitative, qualitative, and mixed-methods systematic and scoping reviews covering factors that influence the implementation of PROMs and PREMs in healthcare settings.

METHODS

An umbrella review of systematic and scoping reviews will be conducted following the guidelines of the Joanna Briggs Institute (JBI). Qualitative, quantitative, and mixed methods reviews of studies focusing on the implementation of PROMs and/or PREMs in all healthcare settings will be considered for inclusion. Eight bibliographical databases will be searched. All review steps will be conducted by two reviewers independently. Included reviews will be appraised and data will be extracted in four steps: (1) assessing the methodological quality of reviews using the JBI Critical Appraisal Checklist; (2) extracting data from included reviews; (3) theory-based coding of barriers and enablers using the Consolidated Framework for Implementation Research (CFIR) 2.0; and (4) identifying the barriers and enablers best supported by reviews using the Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) approach. Findings will be presented in diagrammatic and tabular forms in a manner that aligns with the objective and scope of this umbrella review, along with a narrative summary.

DISCUSSION

This umbrella review of quantitative, qualitative, and mixed-methods systematic and scoping reviews will inform policymakers, researchers, managers, and clinicians regarding which factors hamper or enable the adoption and sustained use of PROMs and PREMs in healthcare settings, and the level of confidence in the evidence supporting these factors. Findings will orient the selection and adaptation of implementation strategies tailored to the factors identified.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023421845.

Development of food literacy in children and adolescents: implications for the design of strategies to promote healthier and more sustainable diets

Food literacy has emerged as a key individual trait to promote the transformation of food systems toward healthy and sustainable diets. Childhood and adolescence are key periods for establishing the foundations of eating habits. Different food literacy competencies are acquired as children develop different cognitive abilities, skills, and experiences, contributing to the development of critical tools that allow them to navigate a complex food system. Thus, the design and implementation of programs to support the development of food literacy from early childhood can contribute to healthier and more sustainable eating habits. In this context, the aim of the present narrative review is to provide an in-depth description of how different food literacy competencies are developed in childhood and adolescence, integrating the extensive body of evidence on cognitive, social, and food-related development. Implications for the development of multisectoral strategies to target the multidimensional nature of food literacy and promote the development of the 3 types of competencies (relational, functional, and critical) are discussed.

Increasing venous thromboembolism risk assessment through a whole hospital-based intervention: a pre-post service evaluation to demonstrate quality improvement

Venous thromboembolism (VTE) is a primary cause of morbidity and mortality in hospitalized patients. VTE risk assessment is a crucial part of the VTE prevention guideline. However, VTE risk assessment was not consistently undertaken for admitted patients. The aim of this study was to identify whether a quality improvement project implemented to change documentation of VTE risk assessment for hospitalized patients impacted patient safety by decreasing the rate of VTE incidences. The study was set in a 600+ bed acute hospital that provides medical and surgical services for adult patients during the period October 2018-September 2020. The hospital adopted the American College of Chest Physicians (ACCP) 9th edition VTE prevention guidelines and followed the Modified Caprini risk assessment tool. Following the FOCUS-Plan-Do-Check-Act (FOCUS PDCA) improvement methodology, the improvement team implemented multicomponent interventions over a 3-month period, including conducting educational sessions, sharing VTE documentation compliance results, giving reminders during rounds, assigning a VTE liaison physician within each clinical specialty, and updating and communicating the hospital adopted VTE guidelines. A total of 17 612 patients were included, respectively, 8971 in pre-intervention and 8641 post-intervention period. Documentation of VTE risk assessment upon admission increased significantly in the post quality improvement intervention period (60% vs. 42%, relative increase of 30%, χ2 = 1.43, P < 0.001). The run chart trend analysis demonstrated significant improvement shift and improvement trend after quality improvement project implementation, and it was sustained for 15 months. There was no impact on patient safety with a slight not statistically significant decrease in the VTE incidences rate post intervention period (0.4% vs. 0.5%, relative decrease of 1%, χ2 = 0.82, P < 0.397). The quality improvement project intervention significantly increased the percentage of patients assessed for VTE risk in a hospital setting.

"We have to change our mindsets": a qualitative study of barriers and facilitators in research collaboration across integrated care system organisations

The introduction of Integrated Care Systems (ICS) in England aimed to increase joint planning and delivery of health and social care, and other services, to better meet the needs of local communities. There is an associated duty to undertake collaborative research across ICS partners to inform this new integrated approach, which might be challenging given that organisations span health, local authority, voluntary and community sector, and research. This study aimed to explore the appetite for collaborative Research and Innovation (R&I) across ICSs, potential barriers and solutions. This qualitative study involved semi-structured interviews with 24 stakeholders who held senior positions within organisations across two ICS areas (Staffordshire and Stoke-on-Trent; Shropshire, Telford and Wrekin). Interview transcripts were analysed using inductive and deductive analysis, first mapping to the Theoretical Domains Framework (TDF), then considering key influences on organisational behaviour in terms of Capability, Opportunity and Motivation from the COM-B Behaviour Change Wheel. There were fundamental limitations on organisational opportunities for collaborative R&I: a historical culture of competition (rather than collaboration), a lack of research culture and prioritisation, compounded by a challenging adverse economic environment. However, organisations were motivated to undertake collaborative R&I. They recognised the potential benefits (e.g., skill-sharing, staff development, attracting large studies and funding), the need for collaborative research that mirrors integrated care, and subsequent benefits for care recipients. Related barriers included negative experiences of collaboration, fear of failing and low confidence. Capability varied across organisations in terms of research skills and confidence, which reflected the range of partners (from local authorities to NHS Trusts, primary care, and academic institutions). These findings indicate a need to shift from a culture of competition to collaboration, and to help organisations across ICS to prioritise research, and share resources and skills to mitigate the limiting effects of a constrained economic environment. This could be further explored using a systems change approach, to develop the collaborative research efforts alongside the overarching move towards integrated care.

Characteristics of patients who return unplanned to the ED, and factors that contribute to their decision to return: Integrated results from an explanatory sequential mixed methods inquiry

AIM

To identify common characteristics of patients who return to the ED unplanned and factors that may contribute to their decision to return.

BACKGROUND

Return visits to the Emergency Department (ED) have been associated with adverse events and deficits in initial care provided. There is increasing evidence to suggest that many return visits may be preventable.

METHODS

The results of primary quantitative measures (QUAN) followed by qualitative measures (qual) were integrated to build on and explain the quantitative data found in the initial phase of the research.

RESULTS

Integration of results produced three new findings. 1) Most return visits occurred beyond 48 hrs because patients intentionally delayed going back to the ED despite their persisting symptoms; 2) Clinical urgency and deterioration were rarely evident in patients who made return visits in patients and 3) Ineffective communication between the clinician and the patient at discharge may have contributed to patients making the decision to return to the ED.

CONCLUSION

The decision to return unplanned to the ED is not an immediate response for most patients, and several potentially avoidable factors may influence their decision-making process. Future research should focus on strategies which contribute to the avoidance of unplanned return visits.

The Gestational Obesity Weight Management: Implementation of National Guidelines (GLOWING) study: a pilot cluster randomised controlled trial

BACKGROUND

Pregnancy weight management interventions can improve maternal diet, physical activity, gestational weight gain, and postnatal weight retention. UK guidelines were published in 2010 but health professionals report multiple complex barriers to practice. GLOWING used social cognitive theory to address evidence-based barriers to midwives' implementation of weight management guidelines into routine practice. This paper reports the pilot trial outcomes relating to feasibility and acceptability of intervention delivery and trial procedures.

METHODS

GLOWING was a multi-centre parallel-group pilot cluster RCT comparing the delivery of a behaviour change intervention for midwives (delivered as training workshops) with usual practice. The clusters were four NHS Trusts in Northeast England, randomised to intervention or control arms. Blinding of allocation was not possible due to the nature of the intervention. We aimed to deliver the intervention to all eligible midwives in the intervention arm, in groups of 6 midwives per workshop, and to pilot questionnaire data collection for a future definitive trial. Intervention arm midwives' acceptability of GLOWING content and delivery was assessed using a mixed methods questionnaire, and pregnant women's acceptability of trial procedures by interviews. Quantitative data were analysed descriptively and qualitative data thematically.

RESULTS

In intervention arm Trusts, 100% of eligible midwives (n = 67) were recruited to, and received, the intervention; however, not all workshops had the planned number of attendees (range 3-8). The consent rate amongst midwives randomised (n = 100) to complete questionnaires was 74% (n = 74) (95% CI 65%, 83%), and overall completion rate 89% (n = 66) (95% CI 82%, 96%). Follow-up response rate was 66% (n = 49) (95% CI 55%, 77%), with a marked difference between intervention (39%, n = 15) and control (94%, n = 34) groups potentially due to the volume of research activities. Overall, 64% (n = 47) (95% CI 53%, 75%) completed both baseline and follow-up questionnaires. Midwives viewed the intervention as acceptable and directly relevant to routine practice. The least popular components related to scripted role-plays. Pregnant women viewed the recruitment and trial processes to be acceptable.

CONCLUSIONS

This rigorously conducted pilot study demonstrated feasibility intervention delivery and a high level of acceptability amongst participants. It has provided information required to refine the intervention and trial protocol, enhancing confidence that a definitive trial could be carried out.

TRIAL REGISTRATION

ISRCTN46869894; retrospectively registered 25th May 2016, www.isrctn.com/ISRCTN46869894 .

Health professionals' practices and perspectives of post-stroke coordinated discharge planning: a national survey

Background It is best practice for stroke services to coordinate discharge care plans with primary/community care providers to ensure continuity of care. This study aimed to describe health professionals' practices in stroke discharge planning within Australia and the factors influencing whether discharge planning is coordinated between hospital and primary/community care providers. Methods A mixed-methods survey informed by the Theoretical Domains Framework was distributed nationally to stroke health professionals regarding post-stroke discharge planning practices and factors influencing coordinated discharge planning (CDP). Data were analysed using descriptive statistics and content analysis. Results Data from 42 participants working in hospital-based services were analysed. Participants reported that post-stroke CDP did not consistently occur across care providers. Three themes relating to perceived CDP needs were identified: (1) a need to improve coordination between care providers, (2) service-specific management of the discharge process, and (3) addressing the needs of the stroke survivor and family . The main perceived barriers were the socio-political context and health professionals' beliefs about capabilities . The main perceived facilitators were health professionals' social/professional role and identity, knowledge, and intentions . The organisation domain was perceived as both a barrier and facilitator to CDP. Conclusion Australian health professionals working in hospital-based services believe that CDP promotes optimal outcomes for stroke survivors, but experience implementation challenges. Efforts made by organisations to ensure workplace culture and resources support the CDP process through policies and procedures may improve practice. Tailored implementation strategies need to be designed and tested to address identified barriers.