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

Promoting self-management in chronic disease: a systematic review and meta-analysis of behaviour change interventions for patients on dialysis

Given the importance of patients' ability to effectively self-manage their kidney disease, researchers have developed interventions focused on improving self-management for patients on dialysis. The review and meta-analysis aimed to evaluate the efficacy of these interventions and identify the characteristics of more effective interventions in this domain. A meta-analysis of randomised controlled trials to promote self-management in patients on dialysis (N = 4201, k = 45) evaluated: the effect of the interventions on psychological, behavioural, and physiological outcomes; the relationships between changes in outcomes; the moderation of outcomes by behaviour change techniques employed in the interventions; and intervention duration. The meta-analysis obtained moderate effect sizes, demonstrating improvement in behavioural (g = 0.50 to 0.65) and physiological health outcomes (g = -0.32 to -0.57). Fewer studies assessed psychological intervention targets, but large effects were obtained for knowledge change and quality of life (g = 0.65 and 1.17, respectively). Improved knowledge was positively associated with improved medication adherence, which in turn was associated with one physiological outcome. Interventions incorporating psychotherapeutic techniques such as CBT or rational emotive therapy achieved superior physiological outcomes, particularly when used in isolation. The findings support the interpretation that intervention strategies to enhance emotional self-management are effective in optimising outcomes for patients on dialysis.

Feasibility and Optimization of Donation Advisor: a Decision Support Tool for Deceased Organ Donation and Transplantation

Background

This study aimed to evaluate the ability of Donation Advisor (DA), a validated clinical decision support tool that uses continuous monitoring, variability analysis, and predictive models, to (i) predict likelihood of successful donation after circulatory determination of death (DCD) before withdrawal of life-sustaining measures (WLSM), and (ii) describe ischemia during WLSM in DCD patients.

Methods

Eligible patients were screened at the 5 sites where DA was implemented. DA reports were generated in real time but shown to clinicians after the donation was complete (noninterventional). Clinicians were interviewed for improvement of the tool.

Results

We enrolled 34 donor patients in the study; 27 had DCD attempts and 20 proceeded to organ recovery. DA reports were generated before WLSM in all 27 attempted DCD patients (100%) while post-WLSM ischemia reports were generated in 26 of 27 DCD attempts (96%). Nineteen of 34 involved clinicians completed interviews, 10 from intensive care, and 9 from transplantation team members. Following a user-centered design approach, feedback was used to create 5 versions. Revisions included additions, removals, clarifications, and formatting changes; the number of revisions decreased with each amendment. The report's predictive scores were found to be useful by most practitioners (83%). We identified barriers and drivers to use the report in future practice, some of which may be addressed through improved education and awareness.

Conclusions

DA can be deployed in real time during the DCD process. The usefulness and usability of the DA report has improved through user feedback; both barriers and drivers to implementation exist.

"Gleaning a lot from the history and physical exam," and "reasonably confident without imaging": a qualitative study of primary care clinicians' management of patients with low back pain

BACKGROUND

Routine seeking of imaging for patients with low back pain is not concordant with the evidence-based recommendation that imaging is rarely of diagnostic value. Inappropriate imaging is a waste of resources and can lead to undesirable downstream effects for individuals and health systems. To develop effective strategies to reduce unwarranted referrals for imaging in primary care, we must understand the drivers for, and barriers to, guideline-adherent practice. We explored clinicians' views to identify the dominant influences on clinicians as they choose to pursue, or avoid, imaging for their patients with low back pain.

METHODS

We interviewed a purposeful sample of 47 primary care clinicians (14 physiotherapists, 18 chiropractors, 15 physicians) throughout Ontario, Canada, with a guide based on the Theoretical Domains Framework (TDF). We investigated clinicians' views about their use of imaging in the management of low back pain. Interviews were recorded and transcribed verbatim. We analysed transcripts, then identified themes within TDF domains.

RESULTS

Most clinicians reported that, for most clinical encounters, they adhered to guideline recommendations about imaging. Many clinicians across disciplines expressed the following themes: (1) imaging may result in an incidental finding or otherwise cause harm to patients, and drive up health system costs (TDF domain Beliefs about consequences); (2) clinicians were confident in their abilities to diagnose, to explain to patients the rationale for not recommending imaging, and to respond to their needs (domains Beliefs about capabilities; Skills). Many clinicians identified that patients occasionally want the validation that imaging provides (domain Social influences). Some clinicians described the value of imaging to corroborate a diagnosis (domain Beliefs about consequences).

CONCLUSIONS

This study is the first to examine influences on imaging behaviours of a large interprofessional sample of primary care clinicians in Canada. Even among knowledgeable, skilled, confident clinicians who reported mostly adhering to guideline recommendations, there are potential influences on deviating from guideline-adherent care.

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.

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.

Knowledge, attitude and practice regarding screening and managing diabetic microvascular complications among general practitioners of community health centres: a cross-sectional study in Shanghai, China

OBJECTIVE

To evaluate the knowledge, attitude and practice (KAP) regarding screening and managing diabetic microvascular complications, encompassing diabetic retinopathy (DR), diabetic kidney disease (DKD) and diabetic neuropathy (DN), among general practitioners (GPs).

DESIGN

Cross-sectional study.

SETTING

The online questionnaire survey was conducted between April and July 2023.

PARTICIPANTS

GPs from community health centres (CHCs) in all 16 districts of Shanghai were recruited.

PRIMARY AND SECONDARY OUTCOME MEASURES

The data of sociodemographic characteristics, KAP scales, training experience and screening instruments for community screening and managing diabetic microvascular complications were collected. Multiple stepwise linear regression was used to explore the influencing factors of KAP. Restricted cubic spline curves with four knots (5%, 35%, 65%, 95%) were used to determine the association between KAP score and duration of general practice.

RESULTS

A total of 1243 questionnaires were included in the analysis. The total KAP score was 66.6±8.8/100, and the knowledge, attitude and practice scores were 64.7±8.7, 83.5±10.5 and 51.6+17.8, respectively. Male (β=-2.419, p=0.012), shorter practice duration (β=-1.033, p=0.031), practice in rural area (β=3.230, p=0.001), not attending training in diabetic microvascular complications (β=-6.346, p<0.001), not managing diabetic patients (β=-4.503, p<0.001), less number of diabetes patients under management (β=-0.007, p=0.035), less number of screening instruments based on self-report of GP (β=-1.681, p<0.001), lower knowledge score (β=-0.190, p<0.001) and lower attitude score (β=-0.414, p<0.001) were associated with lower practice score of GPs. The KAP total score increased with the working years of general practice; however, this effect was no longer observed in knowledge score after 15 years, while the attitude and practice scores showed a continuously increasing trend.

CONCLUSIONS

GPs showed insufficient knowledge and poor clinical practice on screening and managing diabetic microvascular complications. There is an urgent need to improve their capacity to provide better care for those with diabetic microvascular complications through targeted training.

Theory-informed refinement and tailored implementation of a quality improvement program in maternity care to reduce unwarranted clinical variation across a health service network

BACKGROUND

Unwarranted clinical variation presents a major challenge in contemporary healthcare, indicating potential inequalities and inefficiencies, and unrealised potential for better outcomes. Despite an increasing focus on unwarranted clinical variation, and consideration of efforts to address this challenge, evidence-based strategies which achieve this are limited. Audit and feedback of healthcare processes (process auditing) and clinician engagement are important tools which may help to reduce unwarranted clinical variation, however their application in maternity care is yet to be thoroughly explored. We describe the development and implementation of a program to address unwarranted clinical variation across a multi-site maternity network termed Practice Improvement with Clinicians eNgaged in Improving Care (PICNIC). The goals of the program were to engage clinicians to identify and reduce unwarranted clinical variation and enhance the delivery of evidence-based care, with the intention of improving care quality, clinical outcomes, and efficiency of the health service.

METHODS

A theory-informed approach was used to design and implement the four-phase program, underpinned by implementation science and quality improvement methodologies. It utilised clinician-performed process auditing, built upon existing evidence for audit and feedback, and employed evidence-based implementation strategies to promote clinician behaviour change.

RESULTS

The intervention was implemented across the five maternity network sites in 2020 with around 300 clinicians participating in 18 audit topics over four years (2020-2023). A diverse array of evidence-based strategies were utilised to support implementation over this period and are mapped to the Behaviour Change Taxonomy and Expert Recommendation for Implementing Change (ERIC) compilation. Observed benefits of the program include the development and implementation of clinician co-designed system-level improvements that are tailored to context, to improve the delivery of best-practice healthcare and improve outcomes.

CONCLUSIONS

Implementation science theory and quality improvement processes can be integrated pragmatically to engage clinicians to address unwarranted clinical variation, with the objective of creating meaningful behaviour change, and system-level improvements for better healthcare outcomes. The replicability of this approach in other disciplines and hospital networks should be explored.

TRIAL REGISTRATION

Not applicable to this report.

Mapping provider and consumer voices using the AACTT framework: a focus group study of advance care planning

BACKGROUND

The provision of healthcare is complex. When evidence-practice gaps are identified, interventions to improve practice across multi-level systems are required. These interventions often consist of multiple interacting components and behaviours. To effectively address these complexities, it is crucial to first identify the specific roles and actions required at each stage of the intervention. This approach enables a thorough examination of what is working well and what needs to be optimised. The action, actor, context, target, time (AACTT) framework provides a consistent approach to identifying key elements such as 'who' (actor) does 'what' (action), 'where' (context), 'to or with whom' (target) and 'when' (time). To our knowledge the AACTT has not yet been applied: 1) to specify complex interventions across patient journeys; and 2) to investigate consumer views, despite the importance of patient-centred care.

AIM

Using advance care planning (ACP) as an exemplar complex healthcare process, we describe a method for using the AACTT framework to 1) map a complex model of care across a patient journey 2) capture the consumer perspective; and 3) operationalise these perspectives by comparing across groups and identifying alignments or misalignments.

METHODS

Two groups were recruited (healthcare professionals and consumers). Informed by the AACTT framework, four focus groups discussed the process of ACP across existing care pathways. Maps visually representing the perspectives and preferences of healthcare professionals and consumers were co-created iteratively. Qualitative data was deductively coded to the AACTT framework and inductively coded to identify themes within domains. Maps were circulated for critical feedback and refined.

RESULTS

Healthcare professional (n-13) and consumer perspectives (n = 11) highlighted what is 'currently occurring' in practice, what is 'not occurring', and what 'should be occurring' to align practice with consumer preferences of care. Comparing participant perspectives identified that most misalignment occurred within the actor, context, and time domains. Misalignment was found predominantly in actions 'occurring sometimes', with no converging perspectives reported for the context and time domains.

CONCLUSION

This novel application of the AACTT framework systematically brings in the consumer voice in ways that may influence the delivery of care. This approach to specifying healthcare professional and consumer perspectives across a complex care pathway identifies barriers that are not found with traditional mapping methods or in current applications of the AACTT framework.

Combining theory and usability testing to inform optimization and implementation of an online primary care depression management tool

BACKGROUND

The 'Ottawa Depression Algorithm' is an evidence-based online tool developed to support primary care professionals care for adults with depression. Uptake of such tools require provider behaviour change. Identifying issues which may impact use of an innovation in routine practice (i.e. barriers to and enablers of behaviour change) informs the selection of implementation strategies that can be deployed with the tool to support use. However, established theory-informed barriers/enablers assessment methods may be less well suited to identifying issues with tool usability. User testing methods can help to determine whether the tool itself is optimally designed. We aimed to integrate these two methodological approaches to i) identify issues impacting the usability of algorithm; and ii) identify barriers to and enablers of algorithm use in routine practice.

METHODS

We conducted semi-structured interviews with primary care professionals in Ottawa, Canada. To evaluate usability, participants used a written patient scenario to work through the algorithm while verbalizing their thoughts ('Think Aloud'). Participants were then asked about factors influencing algorithm use in routine practice (informed by the Theoretical Domains Framework). We used the codebook approach to thematic analysis to assign statements to pre-specified codes and develop themes pertaining to usability and routine use.

RESULTS

We interviewed 20 professionals from seven practices. Usability issues were summarised within five themes: Optimizing content and flow to align with issues faced in practice, Enhancing the most useful algorithm components, Interactivity of the algorithm and embedded tools, Clarity of presence, purpose, or function of components, and Navigational challenges and functionality of links. Barriers to and enablers of routine use were summarised within five themes: Getting to know the algorithm, Alignment with roles and pathways of influence, Integration with current ways of working, Contexts for use, and Anticipated benefits and concerns about patient communication.

CONCLUSIONS

Whilst the Ottawa Depression Algorithm was viewed as a useful tool, specific usability issues and barriers to use were identified. Supplementing a theory-based barriers/enablers assessment with usability testing provided enhanced insights to inform optimization and implementation of this clinical tool. We have provided a methods guide for others who may wish to apply this approach.

The role of pharmacists in mitigating medication errors in the perioperative setting: a systematic review

INTRODUCTION

Medication errors occur at any point of the medication management process and are a major cause of death and harm globally. The perioperative environment introduces challenges in identifying medication errors due to the frequent use of time-sensitive, high-alert medications in a dynamic and intricate setting. Pharmacists could potentially reduce the occurrence of these errors because of their training and expertise.

AIM

To provide the most up-to-date evidence on the roles and effects of pharmacist interventions on medication errors in perioperative settings.

METHODS

PubMed, CINAHL, and Embase were searched from inception to September 2023. Studies were included if they tested a pharmacist-led intervention aimed at reducing medication errors in adult perioperative settings. The included studies were assessed for quality using the Crowe Critical Appraisal Tool. Data were extracted and synthesized using the DEPICT-2 (Descriptive Elements of Pharmacist Intervention Characterization Tool). Screening, quality assessment, and data extraction were performed by two independent researchers.

RESULTS

Sixteen studies were eligible. All included studies incorporated multicomponent interventions, primarily medication reconciliation (n = 13), medicine-related recommendations (n = 12), staff education (n = 6), and patient counselling (n = 4). The development of implemented interventions was poorly reported across all papers. A diverse range of error reporting was observed, and none of the included studies provided definitions or basis for the categorization of errors. Although the studies showed that pharmacist interventions were associated with a reduction in overall medication errors rates, some studies showed inconsistent findings regarding error subtypes. The most common pharmacist intervention was medication optimization via holding or switching between agents.

CONCLUSION

While there is some evidence of positive impact of the pharmacist-led interventions on medication errors in perioperative setting, this evidence is generally of low quality and insufficient volume. Heterogeneity in study design, definitions, and case detection is common; hence, high-quality research that applies more stringent controls and uses clearer definitions is warranted.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023460812.

Interdisciplinary Oral Nutrition Support and Supplementation After Hip Fracture Surgery in Older Adult Inpatients: A Global Cross-Sectional Survey (ONS-STUDY)

BACKGROUND

Malnutrition predicts poor outcomes following hip fracture, affecting patient recovery, healthcare performance, and costs. Evidence-based guidelines recommend multicomponent, interdisciplinary nutrition care to improve intake, reduce complications, and enhance outcomes. This study examines global variation in oral nutrition support for older (65+ years) hip fracture inpatients.

METHODS

A global survey was conducted as part of a broader program to improve interdisciplinary nutrition care. The protocol was based on evidence-based guidelines, reviewed by experts, and piloted for validity. Recruitment used snowball sampling to achieve diversity across income levels, countries, and healthcare roles.

RESULTS

The survey (July-September 2023) recruited 308 participants from 46 countries across five global regions. Respondents primarily worked in acute teaching (57.5%) and non-teaching (17.5%) hospitals, representing medical (48.4%), nursing (28.2%), and allied health (17.9%) roles. Findings revealed a global knowledge-to-practice gap in multicomponent nutrition care, across providing high-protein/energy food and fluids (median: "half the time"), post-operative provision of oral nutritional supplements (median: "half the time") and continuation for one month with assessment (median: "not very often"), and nutritional education (median: "not very often"). Only 17.9% of respondents reported routine provision ("often" and "nearly always or always") of high-protein/energy food, supplements, and education. Substantial regional variation showed Western Pacific respondents perceiving the lowest provision across multicomponent processes. Interdisciplinary, multicomponent interventions were seen as a potential opportunity requiring further exploration.

CONCLUSIONS

Major gaps persist in implementing evidence-based, interdisciplinary, multicomponent nutrition care for older adults with hip fractures. A targeted implementation approach is the next step to addressing the knowledge-to-practice gap.

Developing an Evidence- and Theory-Informed Mother-Daughter mHealth Intervention Prototype Targeting Physical Activity in Preteen Girls of Low Socioeconomic Position: Multiphase Co-Design Study

BACKGROUND

Preteen girls of lower socioeconomic position are at increased risk of physical inactivity. Parental support, particularly from mothers, is positively correlated with girls' physical activity levels. Consequently, family-based interventions are recognized as a promising approach to improve young people's physical activity. However, the effects of these interventions on girls' physical activity are often inconsistent, with calls for more rigorous, theory-informed, and co-designed family-based interventions to promote physical activity in this cohort.

OBJECTIVE

This study aimed to use co-design methods to develop an evidence- and theory-informed mother-daughter mobile health intervention prototype targeting physical activity in preteen girls.

METHODS

The intervention prototype was developed in accordance with the United Kingdom Medical Research Council framework, the Behaviour Change Wheel, the Theoretical Domains Framework, and the Behaviour Change Techniques Ontology. The Behaviour Change Intervention Ontology was also used to annotate the intervention characteristics. The co-design process incorporated three phases: (1) behavioral analysis, (2) the selection of intervention components, and (3) refinement of the intervention prototype. Throughout these phases, workshops were conducted with preteen girls (n=10), mothers of preteen girls (n=9), and primary school teachers (n=6), with additional input from an academic advisory panel.

RESULTS

This 3-phase co-design process resulted in the development of a theory-informed intervention that targeted two behaviors: (1) mothers' engagement in a range of supportive behaviors for their daughters' physical activity and (2) daughters' physical activity behavior. Formative research identified 11 theoretical domains to be targeted as part of the intervention (eg, knowledge, skills, and beliefs about capabilities). These were to be targeted by 6 intervention functions (eg, education, persuasion, and modeling) and 27 behavior change techniques (eg, goal setting and self-monitoring). The co-design process resulted in a mobile app being chosen as the mode of delivery for the intervention.

CONCLUSIONS

This paper offers a comprehensive description and analysis of using co-design methods to develop a mother-daughter mobile health intervention prototype that is ready for feasibility and acceptability testing. The Behaviour Change Wheel, Theoretical Domains Framework, and Behaviour Change Techniques Ontology provided a systematic and transparent theoretical foundation for developing the prototype by enabling the identification of potential pathways for behavior change. Annotating the Behaviour Change Intervention Ontology entities represents the intervention characteristics in a detailed and structured way that supports improved communication, replication, and implementation of interventions.

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.

Enabling pharmacist prescribing: Lessons learned in Nova Scotia using behaviour change theory

Background

The COVID-19 pandemic alongside increased patient demand, enablement of scope, and government funding has accelerated the need and demand for pharmacist prescribing in Nova Scotia.

Methods

A sequential explanatory mixed-methods study was undertaken to understand barriers and facilitators to pharmacist prescribing in Nova Scotia, Canada. This consisted of: 1) a cross-sectional survey and 2) semistructured, qualitative interviews with pharmacists practising in the community. The survey and interviews were designed using the Behaviour Change Wheel that encompasses the Capability Opportunity Motivation Model of Behaviour Change (COM-B) and Theoretical Domains Framework version 2 (TDFv2).

Results

Of 190 survey respondents, the percentage who prescribed 15+ times/month increased from 49% before to 80% during the COVID-19 pandemic (P<0.001). Pharmacists identified knowledge, social norms/pressures, and rewards or consequences related to how and when to prescribe as facilitators (Knowledge, Social Influences, and Motivation TDFv2 domains, respectively). Barriers included the environmental context and fear of negative outcomes (Environmental Context and Resources and Beliefs about Consequences, respectively). Through the interviews, the presence of prescribing decision tools (Memory, Attention and Decision Processes) and a supportive organizational culture (Environmental Context and Resources) were facilitators. Worry was expressed about making mistakes (Beliefs about Consequences) and feeling significant pressure to meet patient demand (Social Influences) in a busy setting (Environmental Context and Resources).

Discussion

Supports to better enable pharmacist prescribing are described, with key messages for pharmacists, pharmacy owners/managers, educators, advocacy bodies, regulators, and government identified.

Conclusion

Pharmacist prescribing has increased significantly over a short period of time. Environmental supports (e.g., time, space, access to patient records), government funding, peer support, and public awareness are needed to optimize and fully implement these practice changes.

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.

Living with pain and Parkinson's developing an understanding of the impact, trajectory and pain management needs: a qualitative interview study protocol

INTRODUCTION

Pain is reported as one of the most troubling symptoms for people with Parkinson's (PwP); however, the literature exploring their lived experience of pain and how to manage it is limited. Pain affects PwP at all stages of their condition and can fluctuate and change over time. Therefore, it is pertinent to speak to PwP to understand their experiences of pain to inform the development of tailored behavioural interventions to manage pain. How pain interacts with other Parkinson's symptoms lacks consensus. Gaining a better understanding of this from the perspective of PwP is important to inform interventions. Exploring the behavioural determinants, including the barriers and enablers to pain management from the perspective of PwP, the role of healthcare professionals and impact of other symptoms alongside pain will inform the development of a fit for purpose, pain management toolkit for PwP.

METHODS AND ANALYSIS

A longitudinal qualitative study using semi structured interviews at two time points within an 18-month period will be conducted. PwP living with pain will be purposefully sampled from four NHS sites in the North of England. Data will be thematically analysed with reference to the Theoretical Domains Framework.

ETHICS AND DISSEMINATION

A favourable ethical opinion has been granted by the National Health Service East Midlands-Derby Research Ethics Committee (22/EM/0176) and the NHS Health Research Authority (IRAS ID 316403). Findings will be disseminated via scientific conferences, academic journals, lay summaries and public engagement events.

Use of Implementation Science Concepts in the Study of Misinformation: A Scoping Review

Misinformation hinders the impact of public health initiatives. Efforts to counter misinformation likely do not consider the full range of factors known to affect how individuals make decisions and act on them. Implementation science tools and concepts can facilitate the development of more effective interventions against health misinformation by leveraging advances in behavior specification, uptake of evidence, and theory-guided development and evaluation of complex interventions. We conducted a scoping review of misinformation literature reviews to document whether and how important concepts from implementation science have already informed the study of misinformation. Of 90 included reviews, the most frequently identified implementation science concepts were consideration of mechanisms driving misinformation (78%) and ways to intervene on, reduce, avoid, or circumvent it (71%). Other implementation science concepts were discussed much less frequently, such as tailoring strategies to the relevant context (9%) or public involvement in intervention development (9%). Less than half of reviews (47%) were guided by any theory, model, or framework. Among the 26 reviews that cited existing theories, most used theory narratively (62%) or only mentioned/cited the theory (19%), rather than using theory explicitly to interpret results (15%) or to inform data extraction (12%). Despite considerable research and many summaries of how to intervene against health misinformation, there has been relatively little consideration of many important advances in the science of health care implementation. This review identifies key areas from implementation science that might be useful to support future research into designing effective misinformation interventions.

Effect of pharmacist care on clinical outcomes and therapy optimization in perioperative settings: A systematic review

PURPOSE

Integration of pharmacists into the perioperative practice has the potential to improve patients' clinical outcomes. The aim of this systematic review is to systematically investigate the evidence on the roles of pharmacists in perioperative settings and the effects of pharmacist interventions on clinical outcomes and therapy optimization.

METHODS

A protocol-led (CRD42023460812) systematic review was conducted using search of PubMed, Embase, CINAHL and Google Scholar databases. Studies that investigated the roles and impact of pharmacist-led interventions in the perioperative settings on clinical outcomes were included. Data were extracted and quality assessed independently by two reviewers using the DEPICT-2 (Descriptive Elements of Pharmacist Intervention Characterization Tool) and the Crowe Critical Appraisal Tool (CCAT), respectively. Studies were grouped according to the clinical area into 5 sections: (1) pain control and opioid consumption; (2) venous thromboembolism (VTE); (3) surgery-related gastrointestinal complications; (4) postoperative medication management; and (5) total parenteral nutritional.

RESULTS

Nineteen studies involving a total of 7,168 patients were included; most studies were conducted in gastrointestinal (n = 7) and orthopedics (n = 6) surgical units. Most included studies (n = 14) employed a multicomponent intervention including pharmaceutical care, education, guideline development, drug information services, and recommendations formulation. The processes of developing the implemented interventions and their structures were seldom reported. Positive impacts of pharmacist intervention on clinical outcomes included significant improvement in pain control and reductions in the incidence of VTE, surgery-related stress ulcer, nausea, and vomiting. There is inconsistency in the findings related to medication management (ie, achieving desired therapeutic ranges) and management of chronic conditions (hypertension and type 2 diabetes).

CONCLUSION

Whilst there is some evidence of positive impacts of pharmacist intervention on clinical outcomes and optimizing drug therapy, this evidence is generally of low quality and insufficient volume. While this review suggests that pharmacists have essential roles in improving the care of patients undergoing surgery, more research with rigorous designs is required.

Strategies for enhancing the implementation of school-based policies or practices targeting diet, physical activity, obesity, tobacco or alcohol use

BACKGROUND

A range of school-based interventions are effective in improving student diet and physical activity (e.g. school food policy interventions and classroom physical activity interventions), and reducing obesity, tobacco use and/or alcohol use (e.g. tobacco control programmes and alcohol education programmes). However, schools are frequently unsuccessful in implementing such evidence-based interventions.

OBJECTIVES

The primary review objective is to evaluate the effectiveness of strategies aiming to improve school implementation of interventions to address students' (aged 5 to 18 years) diet, physical activity, obesity, tobacco use and/or alcohol use. The secondary objectives are to: 1. determine whether the effects are different based on the characteristics of the intervention including school type and the health behaviour or risk factor targeted by the intervention; 2. describe any unintended consequences and adverse effects of strategies on schools, school staff or students; and 3. describe the cost or cost-effectiveness of strategies.

SEARCH METHODS

We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid), five additional databases, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), and the US National Institutes of Health registry (clinicaltrials.gov). The latest search was between 1 May 2021 and 30 June 2023 to identify any relevant trials published since the last published review.

SELECTION CRITERIA

We defined 'implementation' as the use of strategies to adopt and integrate evidence-based health interventions and to change practice patterns within specific settings. We included any randomised controlled trial (RCT) or cluster-RCT conducted on any scale, in a school setting, with a parallel control group that compared a strategy to improve the implementation of policies or practices to address diet, physical activity, obesity, tobacco use and/or alcohol use by students (aged 5 to 18 years) to no active implementation strategy (i.e. no intervention, inclusive of usual practice, minimal support) or a different implementation strategy.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Given the large number of outcomes reported, we selected and included the effects of a single outcome measure for each trial for the primary outcome using a decision hierarchy (i.e. continuous over dichotomous, most valid, total score over subscore). Where possible, we calculated standardised mean differences (SMDs) to account for variable outcome measures with 95% confidence intervals (CI). We conducted meta-analyses using a random-effects model. Where we could not combine data in meta-analysis, we followed recommended Cochrane methods and reported results in accordance with 'Synthesis without meta-analysis' (SWiM) guidelines. We conducted assessments of risk of bias and evaluated the certainty of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included an additional 14 trials in this update, bringing the total number of included trials in the review to 39 trials with 83 trial arms and 6489 participants. Of these, the majority were conducted in Australia and the USA (n = 15 each). Nine were RCTs and 30 were cluster-RCTs. Twelve trials tested strategies to implement healthy eating practices; 17 physical activity, two tobacco, one alcohol, and seven a combination of risk factors. All trials used multiple implementation strategies, the most common being educational materials, educational meetings, and education outreach visits, or academic detailing. Of the 39 included trials, we judged 26 as having high risks of bias, 11 as having some concerns, and two as having low risk of bias across all domains. Pooled analyses found, relative to a control (no active implementation strategy), the use of implementation strategies probably results in a large increase in the implementation of interventions in schools (SMD 0.95, 95% CI 0.71, 1.19; I2 = 78%; 30 trials, 4912 participants; moderate-certainty evidence). This is equivalent to a 0.76 increase in the implementation of seven physical activity intervention components when the SMD is re-expressed using an implementation measure from a selected included trial. Subgroup analyses by school type and targeted health behaviour or risk factor did not identify any differential effects, and only one study was included that was implemented at scale. Compared to a control (no active implementation strategy), no unintended consequences or adverse effects of interventions were identified in the 11 trials that reported assessing them (1595 participants; moderate-certainty evidence). Nine trials compared costs between groups with and without an implementation strategy and the results of these comparisons were mixed (2136 participants; low-certainty evidence). A lack of consistent terminology describing implementation strategies was an important limitation of the review.

AUTHORS' CONCLUSIONS

We found the use of implementation strategies probably results in large increases in implementation of interventions targeting healthy eating, physical activity, tobacco and/or alcohol use. While the effectiveness of individual implementation strategies could not be determined, such examination will likely be possible in future updates as data from new trials can be synthesised. Such research will further guide efforts to facilitate the translation of evidence into practice in this setting. The review will be maintained as a living systematic review.

The co-design of support strategies for sustainable, healthy and affordable food provision in Early Childhood Education settings

OBJECTIVE

To co-design support strategies to enable sustainable, healthy, affordable food provision, including waste mitigation practices, in Australian Early Childhood Education and Care (ECEC) settings.

DESIGN

Based on the co-design IDEAS framework (Ideate, DEsign, Assess & Share), this co-design process involved iterative interviews and focus groups with ECEC centre staff and workshops with Nutrition Australia. Interview and workshop themes were coded to the Theoretical Domains Framework (TDF) to develop initial prototypes for support strategies that were further developed and refined in focus groups.

SETTING

ECEC with onsite food provision, in Victoria, Australia.

PARTICIPANTS

ECEC staff and a Victorian Government-funded programme delivered through Nutrition Australia that provides nutrition support to ECEC services.

RESULTS

ECEC staff interviews (n 17) suggested a lack of knowledge on the topic of sustainable healthy food provision and a need for resources and support for all staff and children. Workshops with Nutrition Australia built on interviews and suggested a focus on lower intensity strategies and a suggestion to embed knowledge-related activities into the children's curriculum. Focus groups (n 8) further informed co-design of strategies, producing a visual representation of sustainable healthy food provision with supporting tips and a whole-of-centre approach that includes children through a classroom activity.

CONCLUSIONS

The co-designed resources could provide feasible strategies for the adoption of sustainable, healthy and affordable provision practices in the ECEC setting. Involvement of a local government-funded health promotion service provides valuable research-to-practice contribution as well opportunity for scalable dissemination of resources through existing infrastructure.

Same patient but different worlds: A state-of-the-art review translating best practice psychosocial care from musculoskeletal care to the orthopaedic context

BACKGROUND

Individuals with chronic musculoskeletal conditions experience persistent pain and disability that has deleterious impacts on physical function, psychological health, social engagement, relationships, and work participation. This impact is greater in people with psychosocial risk factors, and best practice musculoskeletal care recommends a biopsychosocial approach to management. Orthopaedic surgery is often an effective management approach for chronic musculoskeletal conditions, but research has only recently explored the links between differing patient outcomes after orthopaedic surgery and psychosocial risk factors. Implementing biopsychosocial approaches to musculoskeletal care has taken great strides in the primary care setting however, implementation of the biopsychosocial approach in orthopaedic surgery brings complexity as the context changes from primary care to hospital based secondary care. The aim of this review therefore is to explore implementation of psychosocial care in the elective orthopaedic surgery context, informed by evidence in musculoskeletal care.

ASSESSMENT AND MANAGEMENT OF PSYCHOSOCIAL FACTORS

Several composite screening tools for psychosocial factors or 'yellow flags' are recommended for use in primary care for musculoskeletal conditions alongside a comprehensive patient interview. However, in the orthopaedic surgery context, composite measures have focused on discharge destination, and there is not a universal approach to comprehensive patient interview incorporating a biopsychosocial approach. A range of biopsychosocial approaches to musculoskeletal conditions have been developed for the primary care setting, yet few have been explored in the context of orthopaedic surgery.

IMPLEMENTATION OF PSYCHOSOCIAL CARE

Implementing best practice psychosocial care into the orthopaedic context has enormous potential for all stakeholders, but several barriers exist at the level of the individual patient and practitioner, workforce, health service and society. We have discussed key considerations for implementation including workforce composition, patient-centred care and shared decision making, health literacy, continuity of care, and consideration of preferences for women and culturally diverse communities.

CONCLUSION

This review considers current literature exploring implementation of psychosocial care into the orthopaedic surgery context, informed by current research in musculoskeletal care. This presents a critical opportunity for orthopaedic surgery to provide optimised, equitable, high-value, patient-centred care.

Improving Lynch syndrome detection: a mixed-methods process evaluation of a hybrid type III effectiveness-implementation trial

INTRODUCTION

Translating evidence-based practices into real-world healthcare settings is challenging, particularly in the rapidly evolving field of genomics. A pragmatic two-arm cluster-randomized clinical trial (Hide and Seek Project - HaSP) tested two implementation approaches for improving hereditary cancer referral practices with one key distinction: implementation strategies that were designed 1) explicitly using psychological theory, or 2) using healthcare professional intuition. This mixed-methods process evaluation aimed to provide insights into how and why change occurred by examining contextual determinants, identifying mechanisms of action, and exploring the role of theory.

METHODS

Post-implementation interviews were conducted with Implementation Leads and clinicians from participating HaSP sites. Transcripts were analysed using a mixed inductive and deductive approach, guided by the updated Consolidated Framework for Implementation Research (2.0). Findings were triangulated with other HaSP process evaluation data sources, including HaSP focus group observations, HaSP research team focus groups, MDT observations, and Implementation Lead project logs. Logic models and case studies were developed to articulate causal processes underlying strategy effectiveness and conditions necessary for implementation success.

RESULTS

Eighteen participants from seven HaSP sites were interviewed. Qualitative analysis identified themes related to Lynch syndrome complexity, pandemic disruptions, operational challenges, information technology constraints, multidisciplinary collaboration, cultural determinants, attitudes towards change, the value of theory, adaptations, and implementation support. Within these themes, a total of 39 contextual determinants were identified, with barriers and facilitators spanning 18 CFIR constructs across five domains. Logic models and case studies highlighted a number of mechanisms of action, producing variable clinical outcomes. Process evaluation findings, interpreted together with HaSP trial outcomes, indicate that theory-based implementation strategies may better support Lynch syndrome detection practices compared to intuition-based strategies.

CONCLUSIONS

The information gained from this process evaluation deepens understanding of the factors influencing the success of hospital-specific implementation strategies within the HaSP framework. Potential pathways for optimising the effectiveness of the overall HaSP implementation approach have been identified.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12618001072202. Registered 27 June 2018, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375348&isReview=true .

Maintaining long-term physical activity after cancer: a conceptual framework to inform intervention development

PURPOSE

This paper describes a conceptual framework of maintenance of physical activity (PA) and its application to future intervention design.

METHODS

Evidence from systematic literature reviews and in-depth (N = 27) qualitative interviews with individuals with cancer were used to develop a conceptual framework of long-term physical activity behaviour. Determinants of long-term PA were listed and linked with domains of the Theoretical Domains Framework which in turn were linked to associated behaviour change techniques (BCTs) and finally to proposed mechanisms of action (MoA).

RESULTS

The conceptual framework is presented within the context of non-modifiable contextual factors (such as demographic and material resources) and in the presence of learnt and adapted behavioural determinants of skills, competence and autonomous motivation that must be established as part of the initiation of physical activity behaviour. An inventory of 8 determinants of engagement in long-term PA after cancer was developed. Clusters of BCTs are presented along with proposed MoA which can be tested using mediation analysis in future trials.

CONCLUSION

Understanding the processes of PA maintenance after cancer and presentation of implementable and testable intervention components and mechanisms of action to promote continued PA can inform future intervention development.

IMPLICATIONS FOR CANCER SURVIVORS

This resource can act as a starting point for selection of intervention components for those developing future interventions. This will facilitate effective support of individuals affected by cancer to maintain PA for the long term.

Achieving Benchmarks for National Quality Indicators Reduces Recurrence and Progression in Non-muscle-invasive Bladder Cancer

BACKGROUND

Noncompliance with evidence-based interventions and guidelines contributes to significant and variable recurrence and progression in patients with non-muscle-invasive bladder cancer (NMIBC). The implementation of a quality performance indicator (QPI) programme in Scotland's National Health Service (NHS) aimed to improve cancer outcomes and reduce nationwide variance.

OBJECTIVE

To evaluate the effect of hospitals achieving benchmarks for two specific QPIs on time to recurrence and progression in NMIBC.

DESIGN, SETTING, AND PARTICIPANTS

QPIs for bladder cancer (BC) were enforced nationally in April 2014. NHS health boards collected prospective data on all new BC patients. Prospectively recorded surveillance data were pooled from 12 collaborating centres.

INTERVENTION

QPIs of interest were (1) hospitals achieving detrusor muscle (DM) sampling target at initial transurethral resection of bladder tumour (TURBT) and (2) use of single instillation of mitomycin C after TURBT (SI-MMC).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary and secondary endpoints were time to recurrence and progression, respectively. Kaplan-Meier and Cox multivariable regression analyses were performed.

KEY FINDINGS AND LIMITATIONS

Between April 1, 2014 and March 31, 2017, we diagnosed 3899 patients with new BC, of which 2688 were NMIBC . With a median follow up of 60.3 mo, hospitals achieving the DM sampling target had a 5.4% lower recurrence rate at 5 yr than hospitals not achieving this target (442/1136 [38.9%] vs 677/1528 [44.3%], 95% confidence interval [CI] = 1.6-9.2, p = 0.005). SI-MMC was associated with a 20.4% lower recurrence rate (634/1791 [35.4%] vs 469/840 [55.8%], 95% CI = 16.4-24.5, p < 0.001). On Cox multivariable regression, meeting the DM target and SI-MMC were associated with significant improvement in recurrence (hazard ratio [HR] 0.81, 95% CI = 0.73-0.91, p = 0.0002 and HR 0.66, 95% CI = 0.59-0.74, p < 0.004, respectively) as well as progression-free survival (HR 0.62, 95% CI = 0.45-0.84, p = 0.002 and HR 0.65, 95% CI = 0.49-0.87, p = 0.004, respectively). We did not have a national multicentre pre-QPI control.

CONCLUSIONS

Within a national QPI programme, meeting targets for sampling DM and SI-MMC in the real world were independently associated with delays to recurrence and progression in NMIBC patients.

PATIENT SUMMARY

Following the first 3 yr of implementing a novel quality performance indicator programme in Scotland, we evaluated compliance and outcomes in non-muscle-invasive bladder cancer. In 2688 patients followed up for 5 yr, we found that achieving targets for sampling detrusor muscle and the single instillation of mitomycin C during and after transurethral resection of bladder tumour, respectively, were associated with delays in cancer recurrence and progression.

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.

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®.

Perceived Barriers and Facilitators to Performing Evening Regular Activity Breaks at Home: A COM-B Analysis

BACKGROUND

Experimental research has established the benefits of interrupting prolonged periods of sedentary behaviour in the evening with regular activity breaks. Research should now focus on how people can be encouraged and supported to engage in this behaviour. This study explores the barriers and facilitators unique to performing regular activity breaks in the evening mapped to the Capability Opportunity and Motivation model of Behaviour (COM-B), to inform future free-living intervention development.

METHODS

Individual, face-to-face, semi-structured interviews were conducted with 28 participants (female n = 20, mean (SD) age 25.4 (5.5) years) who had participated in a laboratory-based, evening regular activity breaks intervention. Questions explored barriers and facilitators to incorporating regular activity breaks into their everyday lives at home in the evening. The interview transcripts were analyzed inductively first using thematic analysis, and then mapped, where relevant, to the COM-B model to link the themes to theoretical factors influencing behaviour change.

RESULTS

'Awareness of the benefits' of performing regular activity breaks, along with having the 'Memory and attention required to change behaviour' (e.g., reminders to overcome forgetfulness) influenced participant's psychological capability to perform this behaviour in the evening at home. 'Characteristics of the regular activity break exercises' enhanced physical capability as the exercises were easy and simple. The theme 'Social influences on behaviour' was mapped to social opportunity and described that others present in their home environment could support or hinder the behaviour, dependent on whether they were also taking regular activity breaks or not. 'Motivation' such as working towards a goal (facilitator) or not wanting to interrupt current sedentary behaviours (barrier) explained how reflective motivation, could influence taking regular activity breaks. Additionally, this theme explained how laziness, tiredness and reinforcement of sedentary behaviour via the nature of streaming services could hinder individuals' automatic motivation to perform regular activity breaks in their habitual evening routines.

CONCLUSIONS

Capability, opportunity and motivation were all perceived to influence individuals' ability to interrupt habitual evening sedentary behaviour by performing regular activity breaks. To encourage people to perform this behaviour, a multicomponent intervention is required to improve capability by understanding the benefits, opportunity by utilizing social support and motivation by creating goals and action planning.

Developing an implementation intervention, and identifying strategies for integrating health innovations in routine practice: A case study of the implementation of an insulin patient decision aid

BACKGROUND

Implementation, which is defined as the process of getting evidence-based innovation to be utilised is critical in ensuring innovation is being integrated into real-world practice. The way an implementation intervention (i.e., a bundle of strategies to facilitate implementation) is developed has an impact on the types of strategies chosen, and whether they are relevant to the implementation setting to exert their effects. However, literature pertaining to development of intervention or detailed descriptions of implementation processes are scarce. This study aims to report the development of an implementation intervention to integrate the use of an evidence-based innovation in routine practice, using a Malaysian insulin patient decision aid (PDA) as an exemplar.

METHODS

The development of the insulin PDA implementation intervention was divided into two phases, incorporating step 3 and 4 of the Action Cycle in the Knowledge to Action framework. In Phase 1, barriers to the insulin PDA implementation was explored through qualitative interviews using an interview guide developed based on the Theoretical Domains Framework. In Phase 2, prioritisation of the barriers was conducted using the multivoting technique. Next, potential strategies that can address the barriers were identified based on understanding the clinic context, and evidence from literature. Then, the selected strategies were operationalised by providing full descriptions in terms of its actor, action, action target, temporality, dose, implementation outcome affected, before they were embedded into the patient care pathway in the clinic. The implementation intervention was finalised through a clinic stakeholders meeting.

RESULTS

In Phase 1, a total of 15 focus group discussions and 37 in-depth individual interviews were conducted with: healthcare policymakers (n = 11), doctors (n = 22), diabetes educators (n = 8), staff nurses (n = 6), pharmacists (n = 6), and patients (n = 31). A total of 26 barriers and 11 facilitators emerged and they were categorised into HCP, patient, organisational, and innovation factors. The multivoting exercise resulted in the prioritisation of 13 barriers, and subsequently, a total of 11 strategies were identified to address those barriers. The strategies were mandate change, training workshop, involve patients' family members or caretakers, framing/reframing, inform healthcare providers on the advantages of the insulin PDA use, define roles and responsibilities, place the insulin PDA in the consultation room, provide feedback, systematic documentation, to engage patients in treatment discussions, and juxtapose PDA in preferred language with patient's PDA in their preferred language to help with translation.

CONCLUSION

This study highlights main barriers to PDA implementation, and strategies that can be adopted for implementation. The steps for intervention development in this study can be compared with other intervention development methods to advance the field of implementation of evidence-based innovations.

Development of an evidence-based strategy to implement the HIRAID® emergency nursing framework in rural emergency departments using behaviour change theory

INTRODUCTION

Emergency nurses are critical to emergency care delivery, particularly in rural areas with limited medical support. To support nurses, the validated emergency nursing framework, HIRAID®, was to be implemented. Implementing interventions in the emergency context is notoriously difficult and rural areas have added challenges with limited resources across large geographic areas. This study aims to develop an evidence-informed strategy to implement HIRAID® across a large rural/regional health district.

METHODS

The behaviour change wheel and Theoretical Domains Framework were used in developing the implementation strategy. The theoretical domains, linked to barriers and enablers to implementing HIRAID®, were mapped to intervention functions. Associated Behaviour Change Techniques were considered to determine suitability to address barriers or enhance enablers, as well as suitability according to and the APEASE criteria.

RESULTS

Seven intervention functions, such as modelling, education, and incentivisation, were deemed suitable for inclusion. The intervention functions were mapped to 20 BCTs and planned to be operationalised through 11 delivery modes, including a flexible education program, documentation templates, and support in the workplace.

CONCLUSIONS

This study determined the relevant BCTs and mechanisms of delivery to mediate change in behaviour and support uptake of the HIRAID® emergency nursing framework in a rural health district.

Israeli dentists' knowledge, attitudes, and practices regarding smoking cessation care

BACKGROUND

The 5A's model for brief smoking cessation care (SCC) is recommended for dentists to reduce the negative impacts of smoking on oral health. This study investigates Israeli dentists' adherence to the 5A's guidelines and explores factors influencing their knowledge, attitudes, and practices.

METHODS

An online cross-sectional survey was conducted among Israeli dentists during June-August 2020. The questionnaire included sociodemographic, smoking, and professional characteristics; knowledge (10 true/false statements); attitudes regarding SCC [based on the Theoretical Domains Framework (TDF)] using 13 statements (1-5 Likert scale), for a composite mean attitude score; and 5A's performance (1-5 Likert scale, never to always). Two primary outcomes were analysed: (1) performing all of the 5A's 'often or always'; and (2) performing 'always' the first two steps ("Ask" and "Advise"). Multivariable logistic regression explored the association between the various characteristics and the primary outcomes.

RESULTS

Overall, n = 410 responded. Mean knowledge score was 2.58 (SD = 1.51). Mean attitude score was 2.65 (SD = 0.60). Performance of all 5A's was low with 14.1% (n = 57) reporting completing all 5A's 'often or always', while 34.1% (n = 139) reported 'always' performing 'Ask' and 'Advise'. Specialists had better odds of 'often or always' performing the 5A's (adjusted OR = 2.01, p = .022) and 'always' performing 'Ask and Advise' (adjusted OR = 1.71, p = .022).

CONCLUSIONS

This study highlights the insufficient performance of SCC among Israeli dentists, revealing gaps in knowledge and attitudes related to SCC. Various measures, such as training, automatic referral systems, and integrating SCC as quality measures, may improve SCC provision among Israeli dentists.

Perspectives on the sustained engagement with digital health tools: protocol for a qualitative interview study among people living with Inflammatory Bowel Disease or irritable bowel syndrome

INTRODUCTION

Digital health tools can be beneficial in the care of patients with chronic conditions and have the potential for widespread impact as readily scalable and cost-effective health interventions. However, benefits are often contingent on users sustaining their engagement with these tools over time. Sustained engagement with digital health tools can be challenging, and high rates of attrition from digital interventions are common. Inflammatory Bowel Disease (IBD) and irritable bowel syndrome (IBS) are prominent gastrointestinal conditions resulting in significant burdens for individuals and society. Emerging evidence suggests digital health tools can be beneficial for IBD and IBS management; however, it is not clear what barriers and enablers are experienced by people living with these conditions to sustaining their engagement with these tools, when necessary. Such knowledge could inform the tailoring of new and existing digital health tools to the needs of people living with IBD and/or IBS. This study will seek to identify the barriers and enablers of sustained engagement with digital health tools among adults living with IBD and/or IBS.

METHODS AND ANALYSIS

We will conduct semistructured interviews with a purposive sample of approximately 30 adults (>18 years) who (a) reside in Canada, (b) self-report that they have been diagnosed with IBD and/or IBS, (c) have ever used a digital health tool (ie, any application/platform) to manage their condition and (d) are capable of providing informed consent. Interviews will be audio and video recorded and transcribed verbatim. Data will be coded deductively and barriers and enablers to sustained engagement will be categorised in accordance with the Theoretical Domains Framework. Data analysis will be verified by a patient research partner.

ETHICS AND DISSEMINATION

The study has been approved by the Ottawa Health Science Network Research Ethics Board. The findings will inform the codevelopment of strategies to overcome modifiable barriers and leverage identified enablers of sustained engagement with digital health tools for IBD and IBS care. These strategies can inform the design of new, or modifications to existing, digital health tools for IBD and IBS care where sustained engagement is desirable. Strategies will be compiled into a guidebook and disseminated via the Inflammation, Microbiome and Alimentation: Gastro-Intestinal and Neuropsychiatric Effects (IMAGINE) Strategy for Patient Oriented Research chronic disease network in Canada.

Theoretically informed codesign of a tailored intervention to support pressure ulcer prevention behaviours by older people living in their own homes in the UK and their lay carers: an intervention codesign study (C-PrUP)

OBJECTIVE

To codesign a theoretically underpinned, healthcare practitioner-mediated, tailored intervention to support housebound older patients and their lay carers to adopt pressure ulcer prevention behaviours.

DESIGN

Theoretical domains framework informed codesign.

SETTING

One geographical area in the UK, spanning several community National Health Service Trusts.

PARTICIPANTS

Community-dwelling older patients at risk of pressure ulcer development and their lay carers (n=4) and health practitioners (n=6) providing related care.

RESULTS

Codesigners addressed five identified barriers to pressure ulcer prevention, knowledge and beliefs about consequences, social or professional role and influence, motivation and priorities, emotion and environment. Prioritised intervention components were (1) making every contact count, all health and social care workers to be conversant with basic prevention behaviours and to support and reiterate these at every visit (9.1/10), (2) signposting of existing support groups and sitting services (8.4/10), (3) accessible, timely, trustable and relatable written information including the role of patients, carers and staff in prevention and links to other resources (7.7/10) and (4) supporting close family involvement in some of the practical elements of care (5.6/10).

CONCLUSIONS

Our study sought to codesign a practitioner-mediated, tailored intervention to support housebound older patients and their lay carers to adopt pressure ulcer prevention behaviours. The process of barrier identification and selection of behaviour change techniques for intervention components was theoretically informed. However, further development will be needed to refine the prototype intervention to take into account the complexity of multiple health needs and priorities of patients. The principles of this study are likely to be transferable to similar national and international contexts.

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.

Oral Nutritional Supplementation in Older Adults with a Hip Fracture-Findings from a Bi-National Clinical Audit

BACKGROUND/OBJECTIVES

Evidence-based guidelines and care standards recommend offering oral nutrition supplements to all older adults with hip fracture, not just those already malnourished. This study aimed to identify the proportion of inpatients in a sample of hospitals in two countries that were provided with oral nutritional supplementation (ONS) following a hip fracture and to identify factors associated with ONS provision.

METHODS

An analysis of prospectively collected data from a bi-national Hip Fracture Registry nutrition sprint and registry audit data limited to older adults (≥65 years) undergoing surgical intervention for a fractured hip from 1 to 31 August 2021. Multivariable logistic regression was used to identify factors associated with providing ONS.

RESULTS

Patient-level data was available for 385 older adults (median 85 years; 60.5% female) admitted to twenty-nine hospitals. Less than half (n = 47.3%) of the audited inpatients were provided ONS. After adjusting for covariates, ONS was more likely to be provided to older adults who were identified as malnourished on formal testing (OR 11.92; 95%CI 6.57, 21.69). Other factors associated with prescription of ONS included those who did not have a preoperative medical assessment (OR 2.26; 95%CI 1.19, 4.27) or were cognitively impaired (OR 1.83; 95%CI 1.01, 3.32), severely frail, or terminally ill (OR 3.17; 95%CI 1.10, 9.17).

CONCLUSIONS

ONS was provided in line with evidence-based recommendations for less than half of the older adults with a hip fracture in 29 hospitals in two countries. A structured approach to implementation may be required to reduce complications and improve outcomes for all older adults after a hip fracture, not just those assessed as cognitively impaired, frail, and/or malnourished.

Extubation Advisor: Implementation and Evaluation of A Novel Extubation Clinical Decision Support Tool

IMPORTANCE

Extubation Advisor (EA) is a novel software tool that generates a synoptic report for each Spontaneous Breathing Trial (SBT) conducted to inform extubation decision-making.

OBJECTIVES

To assess bedside EA implementation, perceptions of utility, and identify barriers and facilitators of use.

DESIGN, SETTING AND PARTICIPANTS

We conducted a phase I mixed-methods interventional study in three mixed intensive care unit (ICUs) in two academic hospitals. We interviewed critical care physicians (MDs) and respiratory therapists (RTs) regarding user-centered design principles and usability.

ANALYSIS

We evaluated our ability to consent participants (feasibility threshold 50%), capture complete data (threshold 90%), generate and review EA reports in real-time (thresholds 75% and 80%, respectively), and MD perception of tool usefulness (6-point Likert scale). We analyzed interview transcripts using inductive coding to identify facilitators and barriers to EA implementation and perceived benefit of tool use.

RESULTS

We enrolled 31 patients who underwent 70 SBTs. Although consent rates [31/31 (100%], complete data capture [68/68 (100%)], and EA report generation [68/70 (97.1%)] exceeded feasibility thresholds, reports were reviewed by MDs for [55/70 (78.6%)] SBTs. Mean MD usefulness score was 4.0/6. Based on feedback obtained from 36 interviews (15 MDs, 21 RTs), we revised the EA report twice and identified facilitators (ability to track patient progress, enhance extubation decision-making, and provide support in resource-limited settings) and barriers (resource constraints, need for education) to tool implementation. Half of respondents (9 MDs, 9 RTs; combined 50%) perceived definite or potential benefit to EA tool use.

CONCLUSION

This is the first study of a waveform-based variability-derived, predictive clinical decision support tool evaluated in adult ICUs. Our findings support the feasibility of integrating the EA tool into bedside workflow. Clinical trials are needed to assess the utility of the EA tool in practice and its impact on extubation decision-making and outcomes.

TRIAL REGISTRATION

NCT04708509.

Feasibility of a theory-based intervention towards benzodiazepine deprescribing in Belgian nursing homes: protocol of the END-IT NH cluster-randomised controlled trial

INTRODUCTION

Despite several calls to deprescribe benzodiazepine receptor agonists (BZRA) in older adults, their use among nursing home residents (NHRs) remains high. Therefore, we developed an intervention targeting general practitioners' and healthcare professionals' behaviours regarding BZRA deprescribing in nursing homes (NHs): The END-IT NH (bENzodiazepines Deprescribing InTerventions Nursing homes) 6-component intervention. Before moving on to a large-scale effectiveness and cost-effectiveness evaluation, this feasibility study aims at: (1) assessing the feasibility of the intervention implementation in NHs, (2) assessing the feasibility of conducting a larger-scale evaluation, in terms of recruitment and data collection and (3) conducting an exploratory cost-effectiveness evaluation.

METHODS AND ANALYSIS

We will conduct a cluster-randomised controlled trial in a sample of 6 NHs, with 10-15 NHRs included per NHs. Four NHs will be randomised into the intervention group, and two NHs will deliver usual care (control group). Data collection will occur at baseline, 3, and 6 months (study end). We will collect information to explore implementation fidelity, mechanisms of impact and contextual factors at patient-level, NH-level and healthcare professional-level, using both quantitative and qualitative measures. The feasibility of the study conduction will be assessed by measuring recruitment and attrition rates and completeness of data collection. An exploratory cost-effectiveness evaluation will be conducted based on quality of life and healthcare use and cost data.

ETHICS AND DISSEMINATION

This study protocol received approval from the ethical committee of CHU UCL Namur on the 20 June 2023. All data are confidential and will be anonymised prior to analysis. De-identified data will be shared on a data depository with a 2-year embargo. The results of the study will be disseminated through a scientific paper and will be communicated to local stakeholders and policymakers through a local symposium.

TRIAL REGISTRATION NUMBER

NCT05929443.

Rotator cuff-related shoulder pain (RCRSP): semistructured patient interviews to explore the barriers and enablers to rehabilitation exercises

This study aimed to explore the barriers and enablers to physiotherapist-prescribed rehabilitation exercises for people with rotator cuff-related shoulder pain (RCRSP) and to guide the development of a theoretically informed intervention for people with this condition. Eleven people receiving physiotherapy for RCRSP (M=69 ± 12 years) participated in semistructured interviews. Data were analysed using content analysis, the Theoretical Domains Framework (TDF). The following barriers and enablers were identified in line with the six themes and assigned relevant TDF domains. (1) The impact of previous knowledge and experience on beliefs, (2) therapeutic relationships, (3) expectations around diagnosis, (4) a long and slow pathway to treatment, (5) patients' experience of doing the home exercise rehabilitation programme and (6) seeing positive outcomes. Patients' beliefs that an investigation was necessary to make a diagnosis are incongruent with clinical guidelines. Several enablers identified that influence adherence to shoulder rehabilitation exercises will inform the development of interventions designed to improve adherence. Our findings highlight the importance of educating patients to alleviate identified barriers to self-management for RCRSP. Furthermore, it underscores the need to train healthcare professionals with the necessary skills to effectively educate patients, specifically about misconceptions and uncertainties about the condition and exercise.

Behaviour Change Techniques: An Application to Increase Employees' Willingness to Accept a Salary Reduction

During the COVID-19 pandemic, many organisations worldwide asked their employees to accept a temporary salary reduction to manage the financial consequences of the unprecedented event. In this paper, we use a CEO's salary reduction announcement to all employees and investigate whether a behaviour change intervention using five selected Behaviour Change Techniques (BCTs) increases expat employees' overall willingness to accept a temporary salary reduction. We use mixed qualitative and quantitative methods, including survey and experiment, to test our hypotheses and frame our results. The results show that, while the direction of impact was positive, respondents were overall not significantly more likely to accept a temporary salary reduction. However, a significant effect was found for the individual BCT 'Modelling'. Participants were significantly more likely to accept a pay cut if they knew their senior management took a larger cut than asked of participants. The outcomes of this study suggest that the availability of a financial buffer and the strength of the employer-employee relationship play a, possibly more important, role in employees' willingness to accept a pay reduction. In addition, leadership matters as this study shows that people are more willing to accept a salary reduction when senior management leads the way.

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.

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.

Development of a behaviour change intervention to increase the delivery of upper limb constraint-induced movement therapy programs to people with stroke and traumatic brain injury

PURPOSE

Constraint-induced movement therapy (CIMT) is a recommended intervention for arm recovery after acquired brain injury but is underutilised in practice. The purpose of this study is to describe the development of a behaviour change intervention targeted at therapists, to increase delivery of CIMT.

METHODS

A theoretically-informed approach for designing behaviour change interventions was used including identification of which behaviours needed to change (Step 1), barriers and enablers that needed to be addressed (Step 2), and intervention components to target those barriers and enablers (Step 3). Data collection methods included file audits and therapist interviews. Quantitative data (file audits) were analysed using descriptive statistics. Qualitative data analysis (interviews) was informed by the Theoretical Domains Framework (TDF) and Behaviour Change Wheel.

RESULTS

Fifty two occupational therapists, physiotherapists and allied health assistants participated in focus groups (n = 7) or individual interviews (n = 6). Key barriers (n = 20) and enablers (n = 10) were identified across 11 domains of the TDF and perceived to influence CIMT implementation. The subsequent behaviour change intervention included training workshops, nominated team champions, community of practice meetings, three-monthly file audit feedback cycles, poster reminders and drop-in support during CIMT.

CONCLUSION

This study describes the development of a behaviour change intervention to increase CIMT delivery by clinicians.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, Trial ID: ACTRN12617001147370.

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).

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.

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.