Point-of-care tests to manage acute respiratory tract infections in primary care: a systematic review and qualitative synthesis of healthcare professional and patient views

OBJECTIVES

To review the evidence on healthcare professionals' (HCPs) and patients' views of the use of point-of-care tests (POCTs) in the management of acute respiratory tract infections (RTIs) in primary care settings.

METHODS

We conducted a systematic review of studies up to 28 April 2023. We included studies that included qualitative methods and results; focused on HCPs' and/or patients' views/experiences of POCTs for acute RTIs; and were conducted in primary care settings. We conducted a thematic synthesis to identify how their views on POCTs and interventions can support test use (PROSPERO registration: CRD42019150347).

RESULTS

We included 33 studies, developing 9 categories each for HCP and patient data. We identified 38 factors affecting POCT use: 28 from HCPs and 10 from patients. Factors exist outside and within consultations, and post-consultations, illustrating that some cannot be addressed by HCPs alone. Fourteen interventions were identified that could address factors and support POCT use, with 7 interventions appearing to address the most factors. Some interventions were beyond the scope of HCPs and patients and needed to be addressed at system and organizational levels. Both groups had mixed views on the use of POCTs and highlighted implementation challenges.

DISCUSSION

This review highlights numerous factors affecting POCT use in primary care. Policy-makers planning to implement POCTs are likely to achieve more by providing multi-faceted interventions that target factors outside, within, and post-consultation. Some interventions may need to be already established before POCT introduction. Whilst evidence beyond general practice is limited, similar factors suggest that similar context-tailored interventions would be appropriate.

Barriers and facilitators to the implementation and adoption of computerised clinical decision support systems: an umbrella review protocol

BACKGROUND

The implementation of computerised clinical decision support systems has the potential to enhance healthcare by improving patient safety, practitioner performance, and patient outcomes. Notwithstanding the numerous advantages, the uptake of clinical decision support systems remains constrained, thereby impeding the full realisation of their potential. To ensure the effective and successful implementation of these systems, it is essential to identify and analyse the reasons for their low uptake and adoption. This protocol outlines an umbrella review, which will synthesise the findings of existing literature reviews to generate a comprehensive overview of the barriers and facilitators to the implementation and adoption of decision support systems across healthcare settings.

METHODS

This umbrella review protocol was developed in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines. Searches for eligible articles will be conducted in four electronic bibliographic databases, including PubMed/MEDLINE, IEEE Xplore, Scopus, and Web of Science. Obtained results will be independently screened by four reviewers based on pre-defined eligibility criteria. The risk of bias will be assessed for all eligible articles. Data on barriers and facilitators to the implementation and adoption of clinical decision support systems will be extracted, summarised, and further categorised into themes that aim to describe the originating environment or concept of the respective factor. The frequency of all identified barriers and facilitators within the group of included reviews will be determined in order to establish a prioritisation of the factors.

DISCUSSION

This umbrella review protocol presents a methodology for the systematic synthesis of barriers and facilitators to the implementation and adoption of clinical decision support systems across healthcare settings. The umbrella review will enable the development of novel implementation and adoption strategies that reinforce the identified facilitators and circumvent barriers, thereby promoting the use-oriented evaluation and effective utilisation of clinical decision support systems.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42024507614.

Non-governmental organizations' perceptions of challenges and opportunities for participating in the provision of government-purchased community-based psychiatric rehabilitation services in Shanghai, China: a qualitative study

BACKGROUND

In recent years, the Chinese government has increased its support for the development of community-based psychiatric rehabilitation (CBPR) services and initiated pilot programs for government purchasing of CBPR services from non-governmental organizations (NGOs) in order to address the inadequacy of the government's own supply capacity of CBPR services. This study investigated how the NGOs in Shanghai perceived the challenges and opportunities for participating in the provision of government-purchased CBPR services.

METHODS

A qualitative descriptive approach was employed in this study. The local NGOs' program directors who had been responsible for the provision of government-purchased CBPR services in Shanghai were interviewed regarding their perceptions of the challenges and opportunities. Interview transcripts were coded and analyzed using Braun and Clarke's thematic analysis method.

RESULTS

A total of 19 NGOs' program directors were interviewed. The challenges perceived by them for NGOs to participate in the provision of government-purchased CBPR services included difficulty with engaging individuals with mental illness and their families, lack of resources, lack of knowledge and skills, inadequate collaborations with other stakeholders, and limitations of services. The opportunities could be grouped into external and internal ones. External opportunities included China's favorable policy environment, Shanghai's developed economic environment, and increased public awareness of mental health, while internal opportunities included NGOs' greater flexibility, high team cohesion, stronger focus on the holistic needs of clients, better resource integration capabilities, and ability to provide long-term follow-up and support for clients.

CONCLUSIONS

Based on the findings, recommendations for future actions are provided in the areas of research, public awareness, funding, training, referrals, collaboration, and service designing to improve the mechanism of government purchasing of CBPR services from NGOs in China.

Towards distributed facilitation in research teams: an example from itDf

This essay argues that facilitation is a valuable tool for research teams. It suggests that an external facilitator is particularly helpful for more complex gatherings, and that for smaller or more routine gatherings, building skills within teams to enable the distribution of facilitation across team members is a viable alternative to hiring an external facilitator. Distributed facilitation is a way of supporting internal facilitators by helping to mitigate the time and effort it takes them to manage both process and content.

Development of an implementation intervention to promote adoption of the COMFORT clinical practice guideline for peripartum pain management: a qualitative study

BACKGROUND

Pain management after childbirth is widely variable, increasing risk of untreated pain, opioid harms, and inequitable experiences of care. The Creating Optimal Pain Management FOR Tailoring Care (COMFORT) clinical practice guideline (CPG) seeks to promote evidence-based, equitable acute peripartum pain management in the United States. We aimed to identify contextual conditions (i.e., barriers and facilitators) and discrete implementation strategies (i.e., theory-based actions taken to routinize a clinical practice) likely to influence COMFORT CPG uptake and specify corresponding multi-component implementation interventions at the perinatal quality collaborative- and unit-level.

METHODS

We conducted a qualitative study involving virtual individual interviews and focus groups. Interviews included individuals undergoing childbirth from 2018-2023, (recruited through two online registries), and actively practicing maternity clinicians and surgeons, (recruited via snowball sampling with the eDelphi panel creating the COMFORT CPG), caring for pregnant people in the United States. Focus groups included physicians, midwives, nurses, and unit-based quality improvement (QI) staff working at Michigan hospitals within the Obstetrics Initiative, a statewide perinatal quality collaborative funded by Blue Cross Blue Shield of Michigan and Blue Care Network. The Consolidated Framework for Implementation Research, Expert Recommendations for Implementing Change taxonomy, and Replicating Effective Programs framework informed data collection and analysis. Qualitative content analysis characterized influential contextual conditions, which were linked to implementation strategies and tools using principles of implementation mapping. We then specified multi-component implementation interventions for use by quality collaboratives and unit-based teams.

RESULTS

From May-September 2023, we completed 57 semi-structured individual interviews (31 patients, 26 clinicians) and six focus groups (44 QI champions). Participants identified 10 key conditions influential for COMFORT CPG adoption. Findings enabled identification of five collaborative-level implementation strategies, 27 unit-level implementation strategies, and 12 associated tools to promote COMFORT CPG adoption including the specification of each strategy's hypothesized mechanism of action and each tool's goal and potential uses.

CONCLUSIONS

This work identifies contextual conditions and implementation strategies and tools at the perinatal quality collaborative and unit levels to promote COMFORT CPG adoption on maternity units. These findings may foster more rapid CPG implementation and thereby promote more equitable and evidence-based perinatal pain management care.

[Medication Reconciliation in Primary Care: Practices, Knowledge and Attitudes in the Lisbon and Tagus Valley Health Region]

INTRODUCTION

Despite the importance of medication reconciliation for the continuity of care, there is currently no information on the practices, knowledge, and attitudes of Portuguese family doctors on this subject. This study aimed to characterize the formal medication reconciliation procedures in the Lisbon and Tagus Valley Health Region, as well as the perception of family doctors in this region about what they know, how they think and how they practice medication reconciliation.

METHODS

We conducted an observational, cross-sectional and descriptive study, using two observation units: primary health care units (study 1) and family doctors (study 2) in the Lisbon and Tagus Valley Health Region. Data was collected through two self-completed questionnaires, which were made available online.

RESULTS

A total of 89 primary healthcare units and 208 family doctors participated in the study (31% and 12% response rates, respectively). Only one in four units (n = 22/89) had a formal medication reconciliation procedure. Among the units with a formal procedure, there was variability in some parameters, although all procedures included physicians. More than 70% (n = 150; 72.1%) of family physicians reported having previous contact with the term 'medication reconciliation', and a half (n = 104; 50.0%) reported carrying out medication reconciliation in more than 75% of consultations after hospital discharge. No differences were identified regarding the frequency with which family physicians practice medication reconciliation after hospital discharge depending on age, gender, type of unit where they work, and volume of consultations. Most family physicians (n = 155; 74.5%) included the three steps recommended by the Directorate-General for Health at the time and resolved discrepancies without contacting the hospital physician (n = 168; 88.8%). Family physicians recognize the importance of medication reconciliation (more than 95% agree/completely agree), although the level of agreement regarding their responsibility for this practice is lower.

CONCLUSION

The proportion of primary health care units with a formal medication reconciliation procedure is low. Family doctors in the Lisbon and Tagus Valley Region value medication reconciliation, although they do not include it in all consultations after hospital admission. Communication between levels of care and the standardization of processes are areas with potential for improvement to promote the safe and patient-centered use of medication.

What happens after the funding ends?: A qualitative sustainability investigation of emergency department-based peer support programs implemented as part of Indiana's opioid state targeted response initiative

INTRODUCTION

In 2017, funding disseminated through the US Substance Abuse and Mental Health Services Administration's Opioid State Targeted Response (STR) program accelerated the expansion of peer recovery support services across several states to engage emergency department patients presenting with opioid use disorder. While there is some literature on the initial implementation of these programs, little is known about their sustainability after the STR funding's end. Identifying what happened to these programs is a key component of understanding their ultimate impact and can inform future activities to develop, fund, or sustain similar efforts.

METHODS

We collected qualitative data from six organizations that participated in Indiana's STR-funded Recovery Coaching and Peer Support Initiative (RCPSI). The semi-structured interview guide was designed to gather data related to eight domains of sustainability (i.e., environmental support, funding stability, partnerships, organizational capacity, program evaluation, program adaptation, program evaluation, communications, and strategic planning). The analysts followed a deductive-inductive analysis approach, using the eight domains as an a priori coding structure and developing higher-level inductive themes.

RESULTS

A total of ten individuals (roles included 4 Program Supervisors, 2 Nurse Administrators, a Psychiatric Social Worker, a Mobile Treatment Manager, a Grant Coordinator, and a Vice President of Planning) participated in six interviews. Two programs did not sustain services, primarily because they lacked a sufficient volume of eligible patients to justify services. Factors identified as supporting sustainability in the other four programs included (1) identification of alternate funding sources, (2) evolving internal support for ED-based opioid use disorder treatment, and (3) investment in internal and external relationships. Furthermore, these themes operated across multiple sustainability domains.

CONCLUSIONS

The findings illustrate a dynamic interplay between program context and multiple theorized sustainability domains that impacted the viability of RCPSI programs after the end of STR funding. Results indicate a need for a better understanding of the factors influencing the sustainability of programs supported by federal funding to mitigate the opioid crisis, and such findings will likely apply to a broader range of grant-supported programs.

Payment and billing strategies to support methadone take-home medication: Perspectives of financial leaders of opioid treatment program organizations in New York State

INTRODUCTION

Recent federal regulatory changes governing the delivery of methadone treatment for opioid use disorder at Opioid Treatment Programs (OTPs) support continued practice changes towards greater and flexible methadone take-home medication. Existing payment models for OTPs were closely tied with onsite medication administration and thus misaligned with the need to conduct more and flexible take-homes. This study aims to understand OTP organizations' experience with the newly created OTP bundled payment model in New York State as an alternative to the pre-existing per-service payment model during 2020-2023 to inform financing strategies to support and sustain practice changes.

METHODS

The study conducted semi-structured interviews with financial leaders and staff from OTP organizations in New York State. Purposeful sampling of OTP organizations based on their billing practices was supplemented by snowball sampling. Qualitative data from 12 interviews (with 11 OTP organizations and 1 trade organization) were analyzed with an integrated (inductive and deductive) approach to derive themes.

RESULTS

Study informants recognized that the bundled payment model served to protect revenue in a time when OTPs had to pivot quickly to increase take-home medication to patients. Informants described a wide spectrum of practices to operationalize billing in the alternative payment systems, revealing confusion with the billing rules and significant logistical and technical challenges. Informants expressed concerns regarding the substantial difference between the full bundled rate, paid in weeks with one or more qualifying services, and the medication-only rate, reporting that extended (2 weeks or more) take-homes might not be sustainable under the two-tiered model with the low medication-only rate and advocating for a single bundled rate. Informants believed that increased take-home medication and federal regulatory changes had profound implications for the delivery of counseling services, the counselor workforce, and financial viability for OTPs.

CONCLUSIONS

Our study of OTP organization experience in New York State provided data on OTP organization perspectives regarding the potential revenue-protecting effects of bundled payments and generated insights to inform future research and policy experimentation to support flexible take-home medication. Future implementation studies are needed to better understand the roles of financing strategies at large in supporting clinical practice changes in substance use disorder treatment.

Assessing Emergency Department Staff Knowledge, Competency, and Implementation of Pre- and Post-Trauma-Informed Care Training

INTRODUCTION

Trauma-informed care has been posited as a framework for creating ideal and safe environments for patients to participate in treatment. However, there are limited studies that demonstrate the impact of a focused trauma-informed care training on ED staff. We implemented a 4-hour trauma-informed care training in a general emergency department. We aimed to measure changes in knowledge, opinions, self-rated competency, barriers, and recent practices before and after implementing trauma-informed care training. We hypothesized that the training would result in significant self-reported improvement in all domains.

METHODS

We performed a pre/post interventional study with the intervention being a trauma-informed care training adapted for ED clinical care staff. A validated, publicly available survey tool (Center for Pediatric Stress Trauma-Informed Care [TIC] Provider Survey) was used to assess knowledge, opinions, competency, and utilization of and perceived barriers to trauma-informed care. Pre- and post-training surveys were collected. Responses were stratified by role. Continuous variables were compared using analysis of variance; categorical variables compared using Pearson's chi-square.

RESULTS

Participants demonstrated a high level of perceived knowledge and opinions of trauma-informed care before and after training. We observed significant increases in self-reported competence for all ED staff, some increase in utilization of trauma-informed care in recent practice, and significant decreases in perceived barriers to providing trauma-informed care.

DISCUSSION

Trauma-informed care training is an effective means to improving ED staff self-perceived competence and practice of trauma-informed care even among those with high self-perceived knowledge and opinions of trauma-informed care before the training. Future study should explore the patient-level impact of trauma-informed care training, as well as how to continue to reduce barriers to system-wide implementation of trauma-informed care practices.

Heals on Wheels: Development and Implementation of Community Outreach and Group Medical Visits for People Experiencing Chronic Pain

Background

Chronic pain is a global problem affecting approximately 20% of adults. The prevalence of opioid use for chronic pain has contributed to a widespread crisis of addiction and inadequately managed pain. Though national and international guidelines recommend nonpharmacological, integrative, multi-modal therapies for chronic pain, numerous systemic barriers limit access to these services for those with the highest need and fewest resources.

Objective

This paper describes the development and testing of an innovative "Heals on Wheels" (HoW) community engagement and Group Medical Visit (GMV) program for underserved communities experiencing chronic pain in Hennepin County, Minnesota.

Methods

The HoW program's curriculum was collaboratively adapted from pre-existing Hennepin Health care GMV programs for chronic pain. Free community-based "Appetizer" workshops were developed alongside an 8-week "Full Meal" GMV program titled Easing Pain Holistically (EPH). Three pain-affinity variations of EPH were created (the "Body", "Head", and "Heart") and delivered to 6 cohorts (2 cohorts of each variation). Feasibility was measured by attendance, demographics, and insurance provider information. To evaluate program acceptability, thematic analysis of patients post-GMV weekly progress sheets was performed.

Results

The curriculum for the HoW program included experiential training and education in evidence-based integrative pain management strategies. Fourteen community appetizer workshops (n = 142) were offered in partnership with organizations representing underserved populations. Fifty-five patients completed EPH from 2022 to 2024 with the greatest number of patients in the Heart (n = 23), followed by the Body (n = 19), and the Head (n = 13). Feasibility for the GMV program was demonstrated with average attendance across 6 cohorts at 75.1%. Thematic analysis of qualitative data revealed themes highlighting appreciation for group connection ("sharing") and the EPH program content.

Conclusion

The HoW program shows promise as a feasible and acceptable model of community outreach and engagement to improve access to evidence-based integrative pain care.

Hepatitis C Care in the Greater New Orleans Area: Patient Perspectives on the Barriers and Facilitators to Care

Increasing engagement in hepatitis C virus (HCV) care and treatment will help mitigate HCV incidence, morbidity, and mortality in the United States. This study aimed to understand the multilevel factors affecting engagement in HCV care after implementation of a subscription-based payment model for HCV treatment. Semi-structured interviews were conducted with patients with chronic HCV from a federally qualified health center in New Orleans, Louisiana. We used a convenience sampling method to recruit patients for the study. The interviews conducted between May 2020 and February 2021 explored factors influencing linkage to and retention in HCV care, using the socio-ecological model as the guiding framework. An analysis of the interviews with 39 patients revealed multilevel barriers to care, including instability, provider attitudes, prior care experiences, and the corrections system. Facilitators identified included personal health journey, network HCV experiences, and HCV awareness. A multilevel approach to facilitate engagement in HCV care is imperative.

Evidence-informed decision-making in public health in Canada: a qualitative exploration

INTRODUCTION

Evidence-informed decision-making (EIDM) plays a vital role in public health practice. Canada has invested in support for evidence-informed approaches in public health. Despite growing expectations for EIDM, evidence integration has not been thoroughly evaluated.

OBJECTIVE

This study explores EIDM within Canadian public health organizations before the COVID-19 pandemic. A secondary objective is to explore how EIDM in public health was affected by the COVID-19 pandemic.

METHODS

Using a qualitative descriptive approach, data were collected and analyzed from interviews with public health professionals across Canada.

RESULTS

From interviews with 20 participants in four Canadian provinces and one territory, all participants noted that EIDM was valued, but there was considerable variation in implementation. Participants reported differences in consistency of evidence use, resources available at their public health organizations to support EIDM, and staff knowledge and skills in EIDM. Leadership emerged as a strong influencer of EIDM; however, leadership investment in EIDM varied. Changes in evidence use during the COVID-19 pandemic revealed an urgency for decision-making amidst an influx of evidence and reallocated staff roles.

CONCLUSIONS

Despite gains in the recognized value of EIDM, gaps remain in the integration of evidence into decision-making and adequate resource investment to support EIDM. Time, resources, and skills to adapt processes and implement EIDM are needed for public health organizations in Canada to fully integrate EIDM into all aspects of public health decision-making.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A249.

The Hidden Complexity of Virtual Mindfulness-Based Group Medical Visits: Comfort, Challenge, and the Influence of Social Determinants of Health

Background

Chronic low back pain is globally prevalent and associated with significant impairment in quality of life. Furthermore, people from historically marginalized communities are less likely to receive treatment, contributing to health inequities. Group mindfulness-based interventions improve pain and function, and virtual delivery has been demonstrated to be feasible. Little is known about how participants experience the virtual delivery of mindfulness-based interventions, especially participants from historically marginalized communities.

Objective

This study explored participant perspectives of a virtual mindfulness-based group medical visit for people with chronic low back pain.

Methods

Participants were recruited from the intervention arm of OPTIMUM, a study of virtual medical group visits using an adapted Mindfulness-Based Stress Reduction program for chronic low back pain. Semi-structured exit interviews were examined, and reflexive thematic analysis was used to compose key themes.

Results

Interviews from 59 participants (mean 56 years, 69.5% women; 45.8% Black or African American) were examined. Two major themes were derived from analysis. The first theme was 'effects of the external environment,' ie, the physical location from which the participant engaged with the session. The subthemes were comfort, social demands in the home setting, and sharing personal spaces. The second theme was 'navigating the virtual platform.' Subthemes were ease, struggle, and levels of support.

Conclusion

Patient experiences varied substantially during the virtual mindfulness-based group medical visit intervention and this variation was influenced by social determinants of health. The key themes bring attention to the effects of the external environment and the technology itself on participation for people from historically marginalized communities. Basic tenets of mindfulness, such as present state awareness and equanimity, can provide a structure within which to navigate virtual participation amid home environments. Future studies are needed to explore differences in virtual and in-person mindfulness programs and to adapt virtual mindfulness programs.

Clinicaltrialsgov ID number

NCT04129450.

Improving audit and feedback: A user-centred approach to designing feedback techniques for an online experiment

Objective: Audit and feedback (A&F) programmes aim to improve patient care by providing summary data on performance to clinicians. They generally have modest, but variable, effects on patient care and questions remain about how best to provide performance feedback. It is not feasible to test all ways of providing feedback in 'real-world' randomised trials. Online screening experiments that screen feedback techniques prior to real-world evaluations of optimised versions offer a systematic approach. User-centred design methodologies can inform the design of such online experiments. Methods: We report the use of an innovative user-centred design approach to create feedback techniques for an online screening experiment and reflect on its usefulness. This approach included the involvement of patients and stakeholders. Results and Conclusion: We highlight lessons on ways to engage with partners, considering the feasibility of online A&F feedback delivery, fidelity, and usability. We demonstrate how the approach was implemented to co-create a set of feedback techniques for an online experiment and could also be applied to the design of other digital interventions.

Employer-Sponsored Medicare Advantage Plans and the 2018 Therapy Cap Repeal: Reduced Overall Spending Does Not Constrain Out-of-Pocket Costs

BACKGROUND

Policy impacting traditional Medicare beneficiaries may have unintended effects for privately insured patients. After the repeal of a longstanding $1500 outpatient therapy cap in 2018, we aimed to evaluate if this policy change was associated with differences in use of cost of postoperative therapy after common hand surgeries, including carpal tunnel release, trigger finger release, ganglion cyst excision, De Quervain tenosynovitis release, carpometacarpal arthroplasty, and distal radius fracture open reduction/internal fixation or percutaneous pinning.

METHODS

The Medicare Supplement and Coordination of Benefits files from Marketscan were used. Frequency of therapy appointments, overall costs, and out-of-pocket costs were obtained. A segmented interrupted time series with Poisson and log-transformed linear regression was performed.

RESULTS

No significant monthly change in odds of therapy use was found in the postpolicy period for patients who underwent trigger finger release, carpal tunnel release, Ganglion cyst excision, De Quervain tenosynovitis release, carpometacarpal arthroplasty, or distal radius fracture, pinning, or open reduction/internal fixation. Overall cost decreased in the postpolicy period by 2% for comprehensive plans (95% confidence interval [CI]: -0.03 to -0.01, P < 0.001), by 7% for those with exclusive provider organizations (95% CI: -0.10 to -0.04, P < 0.001), by 1% for HMOs (95% CI: -0.01 to 0.002, P = 0.01), and by 3% for preferred provider organizations (95% CI: -0.03 to -0.02, P < 0.001). In the postpolicy period, no monthly change in out-of-pocket cost was observed for patients with comprehensive, exclusive provider organization, health maintenance organization, preferred provider organization, or point of service with capitation insurance plans.

CONCLUSIONS

Patients with employer-sponsored Medicare Advantage plans experienced increased out-of-pocket costs for therapy despite lower net costs. These data highlight an urgent need for policy ensuring that patients benefit when overall costs of care decrease.

How does trauma informed care education for paediatric healthcare professionals' impact self-reported knowledge and practice. An integrative review

AIM

To examine the literature on the impact of Trauma Informed Care education on paediatric health care practitioners' self-reported knowledge and practice.

BACKGROUND

Psychosocial trauma during childhood is prevalent and linked to increased risk of adverse physical and mental health outcomes. Trauma Informed Care recognises the significant impact of childhood trauma in health outcomes. Education is key to health care practitioners' integrating Trauma Informed Care into practice.

DESIGN

Integrative review of the literature.

METHODS

The review employed Whittemore and Knafl's (2005) framework and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2021 statement. A systematic search of Medline, CINAHL and SCOPUS, covering 2019 toMay 2024. Data were critically appraised using the Mixed Methods Appraisal Tool.

RESULTS

Nine studies were included, identifying four themes using Braun and Clarke's thematic analysis: (1) 'awareness and understanding', (2)'self-efficacy and feeling competent', (3)'applying knowledge to practice' and (4)'barriers to implementation'. Following educational intervention, health care practitioners experienced increased knowledge regarding prevalence and impact of trauma for children and families and developed confidence to respond with trauma informed practices.

CONCLUSIONS

Findings closely relate to the four components of Trauma Informed Care practice; realising the widespread impact of trauma, recognising symptomology, responding through integrating trauma knowledge into policies and practice and resisting re-traumatisation. The findings illustrate that Trauma Informed Care educational interventions significantly improves health care practitioners' knowledge and practice. In addition, this review supports the implementation of routine Trauma Informed Care education and associated practice policies into paediatric practice settings.

"Pushed to Their Limits": Health Care Provider Perspectives on Barriers and Facilitators to Implementing a Mind-Body and Activity Program for Older Adults With Chronic Pain in a Community Clinic for the Underserved

Older adults from underserved backgrounds experience chronic pain at a rate of 60% to 75%. Pharmacological treatments have limited efficacy and involve considerable risks. Mind-body interventions hold promise to improve pain outcomes but are typically not implemented in community clinics in which they are needed most, thus contributing to health disparities in chronic pain treatment. We conducted qualitative focus groups and interviews with 20 providers (eg, primary care doctors, nurses, administrators). We sought their perspectives on barriers and facilitators to implementing an evidence based mind-body activity program for older adults with chronic pain at an underserved community health clinic in Massachusetts. Subthemes were identified within 2 superordinate domains (barriers and facilitators) using a hybrid inductive-deductive thematic analysis approach following the Framework Method. Providers discussed facilitators (partner with clinic staff to facilitate referrals and buy-in, integrate referrals through the electronic medical record, offer groups in different languages, post and tailor advertisements) and barriers (limited staff bandwidth, scheduling challenges, inconsistent patient participation). These results will directly inform tailoring and subsequent effectiveness testing and implementation of the pain management program for older underserved adults with chronic pain in this community health care setting.

"Placing community in the driver's seat": Key strategies and critical enablers of an equitable place-based COVID-19 vaccination response

Addressing health inequities requires both national and local-level action. In the case of COVID-19, locally-led place-based programs were instrumental in addressing vaccination inequities that resulted from implementation gaps in national and state-level universal COVID-19 vaccination programs. To prepare for future pandemics, understanding which local strategies are effective and the conditions that enable their effectiveness is crucial. We conducted a case study using qualitative interviews (n = 22) and document analysis to identify key strategies employed to increase vaccination uptake among priority populations in a regional community in Victoria, Australia, and the conditions perceived to enable or constrain the success of those strategies. Interviewees included Aboriginal and migrant community members (n = 12) and representatives from organisations that designed and implemented the COVID-19 vaccination program (n = 10). Strategies perceived to be effective by local migrant and Aboriginal communities included the location of outreach clinics (places considered physically, cultural and political accessible and safe), communication via trusted community leaders, practical supports such as translation services and transport, and empowering community in clinical interactions. Conditions perceived to influence program implementation and outcomes related to four themes: (i) shared vision and strong bonds of local partners, (ii) placing community in the driver's seat, (iii) rebalancing power through leadership grit and guts, and (iv) equity-enabling service and funding models. Our study supports strengthening of national and state government investment and engagement with local partnerships to place equity and community at the centre of future pandemic and public health responses.

Integrated programs for common mental illnesses within primary care and community settings in Latin America: a scoping review of components and implementation strategies

Integrated programs for common mental illnesses are evidence-informed practices yet to be routinely implemented in Latin America. It synthesizes the literature on integrated programs for common mental illnesses (anxiety, depression, and posttraumatic stress disorder) in Latin American primary care and community settings. It maps program components (the 'what') to the collaborative care model core components and implementation strategies (the 'how') to the Expert Recommendations for Implementing Change (ERIC) taxonomy. Results from 18 programs across six countries (Belize, Brazil, Chile, Colombia, Mexico, Peru) show wide heterogeneity in component and strategy combinations. Overall, provider-level components and strategies were more common than family- or community-level ones. 'Team-based care' was the most commonly reported component, and 'family/user engagement' the least. The most common implementation strategy was 'supporting clinicians,' while 'changing infrastructure' was the least. Programs commonly addressed depression and only four followed experimental designs. We found limited evidence on the potential mechanisms of integrated program components and strategies.

Barriers and Facilitators to Colorectal Cancer Screening Among Health Fair Attendees in Utah

BACKGROUND

Colorectal cancer (CRC) screening uptake remains suboptimal despite the importance and effectiveness of various testing options. The purpose of our study was to identify barriers and facilitators to CRC screening in a community-based sample in Salt Lake County, Utah to inform future efforts to develop effective interventions to increase CRC screening.

METHODS

This study enrolled adults eligible for CRC screening at 6 community health events. Participants completed targeted questionnaires based on whether they had discussed screening with a provider and whether they had received screening. We identified participant-reported barriers to CRC screening using descriptive analysis. Univariate and multivariate analyses were used to identify participant characteristics associated with receipt of screening.

RESULTS

Of the 117 participants who completed the questionnaires, 43.6% were 50 to 60 years old, 36.8% identified as white, and 51.3% identified as non-Hispanic. The most common barrier to colonoscopy was the need for extensive bowel preparation (30.8%). For stool tests, common barriers included handling stool (20.5%) and not understanding how to do the test (20.5%). For virtual colonoscopy, barriers included the need for extensive bowel preparation (21.4%) and cost (21.4%). Most participants (67.5%) believed that they should know about all CRC screening options available, and their importance. The majority of participants (68.4%) preferred to learn about CRC screening from their doctor or healthcare provider. Younger age was associated with non-screening.

CONCLUSION

We observed that study participants faced procedural barriers to complete CRC screening and preferred to learn about CRC screening options through their providers. Younger age groups were less likely to receive screening within our study sample. Future, targeted interventions to increase CRC screening should focus on increasing the awareness of the importance of CRC screening and educating patients on the various screening options available and their benefits, especially as they pertain to less invasive tests and targeting younger individuals.

Challenges and Opportunities in Implementing a Multicomponent Dementia Caregiver Program in a Complex Healthcare System

The Tailored Activity Program (TAP), an intervention for people living with dementia (PLWD) and their caregivers, has been shown to reduce behavioral symptoms for PLWD and caregiver burden. While TAP is proven as an evidence-based practice (EBP), it has yet to be implemented at scale. The Department of Veterans Affairs (VA) has prioritized the Age-Friendly Health System (AFHS) initiative, providing an opportunity to test implementation of TAP in a complex healthcare system. We conducted semi-structured pre-implementation interviews with leaders and clinicians at 6 VA Medical Centers (VAMCs) to engage key implementation partners and understand their unique implementation contexts. We utilized team-based rapid qualitative analysis to identify themes related to implementation determinants. We interviewed 65 unique informants in 58 interviews (5 VAMC leaders, 36 department leaders, and 17 frontline clinical staff). Informants identified 4 key factors critical to consider prior to implementing TAP: (1) alignment with organizational priorities; (2) perceived value and fit with existing clinical workflows; (3) competition with existing organizational and clinical priorities; and (4) considerations about the effect of caregiver burden on participation. We identified key factors to consider for successful implementation of a multicomponent intervention for PLWD and their caregivers within a complex healthcare system. As the AFHS initiative expands, there is a growing need for EBPs focused on the care of PLWD and their caregivers. These factors can guide clinicians, leaders, and implementation scientists in planning for implementation and sustainment of EBPs to bolster AFHS initiatives.Trial RegistrationRegistered 05 May 2021, at ISRCTN #60,657,985.Reporting GuidelinesThe COnsolidated criteria for REporting Qualitative research (COREQ) checklist was used to ensure proper standards for reporting qualitative studies (see attached).

[From evidence to practice: The Disemination and Implementation Science in primary care]

Dissemination and Implementation Science focuses on bridging the gap between scientific research and its practical application in the real world. By identifying and promoting effective strategies, the Science of Dissemination and Implementation disseminates and implements evidence-based interventions in healthcare settings, taking into account the needs, barriers, context, resources, and end users. This special article introduces and debates the most recent advances in this field, highlighting key approaches, theoretical frameworks, as well as specific challenges and opportunities applied to primary and community care. Additionally, concrete examples tailored to the Spanish context are presented. Given the nascent state of the use of the Dissemination and Implementation Science in Spain, the authors recommend strategically adopting this approach and its principles in primary and community care to expedite the adoption of effective interventions that promote health.

Delivery of enhanced asthma care in pharmacies: Perceptions and experiences of Australian service providers

BACKGROUND

Evidence-based asthma management services have been tested in Australian community pharmacies for over 2 decades and have been well received by patients but are not retained in practice. The positive clinical outcomes of these tested services suggest the potential for wider implementation, for which the providers' perspective is critical.

OBJECTIVE

This investigation evaluates the implementability of the Pharmacy Asthma Service (PAS) through the experiences and perceptions of the community pharmacists delivering the service.

METHODS

Forty-eight pharmacists took part in a posttrial semi-structured qualitative telephone interview, representing 42 of 51 (82%) eligible PAS intervention arm pharmacies. Qualitative data were deductively analyzed in accordance with the Implementation Outcomes Framework.

RESULTS

Pharmacists recognized the positive impact of the service on patients' health outcomes, the pharmacist's practice, and in fostering stronger and more beneficial pharmacist-patient relationships. However, whilst acknowledging the importance of such a service, the pharmacists faced challenges in recruitment and patient follow-up. Pharmacists stated that further work is required to address pharmacist and patient time constraints, patient health beliefs and to increase the acceptance of pharmaceutical care provision in community pharmacy practice by patients and other health care professionals.

CONCLUSION

Pharmacists can deliver enhanced clinical care for asthma patients with positive perceived professional and patient outcomes. However, it remains evident that time, remuneration, and recognition of the pharmacist's role in chronic care management form barriers to the implementation of asthma services in community pharmacies. Broader policy and systemic changes are required to successfully balance medication supply and quality patient management roles at the same time as a required shift in research processes.

Human-centered design approach to building a transition readiness mHealth intervention for early adolescents

OBJECTIVE

Mobile health (mHealth) interventions may be an efficacious strategy for promoting health behaviors among pediatric populations, but their success at the implementation stage has proven challenging. The purpose of this article is to provide a blueprint for using human-centered design (HCD) methods to maximize the potential for implementation, by sharing the example of a youth-, family-, and clinician-engaged process of creating an mHealth intervention aimed at promoting healthcare transition readiness.

METHOD

Following HCD methods in partnership with three advisory councils, we conducted semistructured interviews with 13- to 15-year-old patients and their caregivers in two phases. In Phase 1, participants described challenges during the transition journey, and generated ideas regarding the format, content, and other qualities of the mHealth tool. For Phase 2, early adolescents and caregivers provided iterative feedback on two sequential intervention prototypes. Data were analyzed using thematic analysis in Phase 1 and the rapid assessment process for Phase 2.

RESULTS

We interviewed 11 youth and 8 caregivers. The sample included adolescents with a range of chronic health conditions. In Phase 1, participants supported the idea of developing an autonomy-building tool, delivering transition readiness education via social media style videos. In Phase 2, participants responded positively to the successive prototypes and provided suggestions to make information accessible, relatable, and engaging.

CONCLUSIONS

The procedures shared in this article could inform other researchers' plans to apply HCD in collaboration with implementation partners to develop mHealth interventions. Our future directions include iteratively developing more videos to promote transition readiness and implementing the intervention in clinical care.

Implementation of a novel pain coach educator program in a safety-net emergency department

Introduction

The ongoing opioid epidemic and rising number of patients with chronic pain highlight the need for alternative and integrative pain management approaches as a strategy to reduce opioid use and misuse. Evidence-based nonpharmacologic pain management strategies are available; however, they remain underutilized due to barriers including time limitations, cost, and lack of training. To address these barriers, we implemented a pain coach educator pilot program and nonpharmacologic patient toolkit in the emergency department of a large safety-net hospital. This paper describes the implementation process and preliminary evaluation of the first year of the program.

Method

We implemented a multimodal pain coach educator program that included education on pain neuroscience and over-the-counter analgesic options, demonstration of integrative techniques, and dissemination of nonpharmacologic toolkits for home use in January 2021. Implementation strategies included changing the electronic health record infrastructure, developing stakeholder interrelationships, and ongoing education and training. We used the RE-AIM framework to guide evaluation of the first year of program implementation using data from the electronic health record, program records, and patient-reported outcomes.

Results

In the first year of program implementation, 550 pain coach educator sessions were conducted. Upon session completion, 61% of patients felt the program was helpful, 39% were unsure at the time, and none reported session was not helpful. Clinician feedback was overwhelmingly positive. Program cost per patient was $344.35. Adaptations to intervention and implementation strategies included modifications of session delivery timing to accommodate clinical workflows, additions to program content to align with patient characteristics, and changes to patient identification strategies in response to the COVID-19 pandemic.

Conclusions

Our pain coach educator program provides a model for implementing nonpharmacologic pain management opioid alternatives which can be scaled and adapted for other settings. This work demonstrates the importance of intervention and implementation strategy adaptations to enhance program reach and effectiveness.

The effect of caregiver opinion leaders to increase demand for evidence-based practices for youth anxiety: A cluster randomized controlled trial

Background

Dissemination initiatives have the potential to increase consumer knowledge of and engagement with evidence-based treatments (e.g., cognitive behavioral therapy [CBT]). Opinion leaders (OLs) have been used in public health campaigns, but have not been examined for the dissemination of mental health treatments. This study uses the Theory of Planned Behavior to test the dissemination strategy of involving an OL in an educational presentation to increase caregiver demand for CBT for youth anxiety.

Method

Participants (N = 262; 92% female; 69% White, 82% non-Hispanic) were caregivers who registered for a virtual presentation on youth anxiety treatment through their child's school. Schools within 1.5-hr drive of Philadelphia, PA were cluster-randomized (k = 25; two-arm prospective randomization) to the OL condition (presented by a clinical researcher and local caregiver OL; n = 119 participants) or the researcher-only condition (n = 143 participants). Presentations occurred from May 2021 to May 2022. Measures were completed pre- and post-presentation and at 3-month follow-up.

Results

Relative to the researcher co-presenter, participants rated the OL as significantly more relatable, familiar, similar, and understanding of their community, but less credible than the researcher co-presenter. In both conditions, there was a significant pre-post increase in participants' knowledge of, attitudes about, subjective norms related to, and intention of seeking CBT for youth anxiety, but not stigma. Presentation conditions did not differ in change on these measures, or on rates of seeking youth anxiety CBT at follow-up.

Conclusions

Although involvement of a caregiver OL did not increase caregiver demand for evidence-based treatment for youth anxiety, the outreach presentation was associated with increases in knowledge of, attitudes about, subjective norms related to, and intention to seek CBT for youth anxiety. Involving OLs in researcher-delivered dissemination efforts may not be necessary for all consumer audiences, but may be beneficial for engendering a sense of relatability, similarity, and connection with disseminators.

Mixed-Method Evaluation to Understand Clinician Perspectives of a Program to Implement High-Intensity Resistance Rehabilitation Into Skilled Nursing Facilities

OBJECTIVE

To assess rehabilitation clinicians' viewpoints regarding a multicomponent implementation program aimed at promoting high-intensity resistance rehabilitation (HIR), as well as practical implications for its use in skilled nursing facility (SNF) rehabilitation.

DESIGN

Prospective convergent mixed-method design.

SETTING

Eight rural SNFs within the Department of Veterans Affairs.

PARTICIPANTS

Physical rehabilitation clinicians (physical and occupational therapists, physical and occupational therapy assistants, recreational therapists, and kinesiotherapists) who engaged with the implementation program (n=38).

INTERVENTIONS

Clinicians engaged with the multicomponent implementation program to promote the use of HIR in clinical practice. The program components included clinician training (i.e., virtual didactic modules with synchronous case discussions), provision of resources (e.g., equipment, job aids), and facilitated implementation (e.g., external implementation facilitator support, distributed tips and tricks).

MAIN OUTCOME MEASURES

Acceptability of Intervention Measure, Training Acceptability Rating Scale, study-specific questionnaires, and qualitative focus groups exploring perceived acceptability, feasibility, and effect on work experience.

RESULTS

Questionnaires revealed high levels of implementation program acceptability and perceived effect, alongside moderate levels of feasibility. Focus group themes supported these findings, explaining high acceptability and effect through differentiation from other trainings and prolonged engagement. Feasibility results were explained qualitatively by facilitatory factors (i.e., team participation, reduced caseloads, training characteristics) and inhibitory factors (i.e., training timing, self-paced scheduling logistics, lack of protected time and space). There was no reported negative effect on clinician work experience.

CONCLUSIONS

According to SNF clinician perspectives, a positive HIR implementation experience may be enhanced through implementation programs that provide prolonged engagement and a self-paced structure with built-in accountability. Leadership and organizational support appear important to protect time and space for clinicians who experience competing priorities to successfully facilitate evidence uptake. Future work can evaluate the applicability across various contexts beyond rural VA SNFs.

Considerations for using participatory systems modeling as a tool for implementation mapping in chronic disease prevention

Effective chronic disease prevention requires a systems approach to the design, implementation, and refinement of interventions that account for the complexity and interdependence of factors influencing health outcomes. This paper proposes the Participatory Implementation Systems Mapping (PISM) process, which combines participatory systems modeling with implementation strategy development to enhance intervention design and implementation planning. PISM leverages the collaborative efforts of researchers and community partners to analyze complex health systems, identify key determinants, and develop tailored interventions and strategies that are both adaptive and contextually relevant. The phases of the PISM process include strategize, innovate, operationalize, and assess. We describe and demonstrate how each phase contributes to the overall goal of effective and sustainable intervention implementation. We also address the challenges of data availability, model complexity, and resource constraints. We offer solutions such as innovative data collection methods and participatory model development to enhance the robustness and applicability of systems models. Through a case study on the development of a chronic disease prevention intervention, the paper illustrates the practical application of PISM and highlights its potential to guide epidemiologists and implementation scientists in developing interventions that are responsive to the complexities of real-world health systems. The conclusion calls for further research to refine participatory systems modeling techniques, overcome existing challenges in data availability, and expand the use of PISM in diverse public health contexts.

Strategies and Outcomes of Age-Friendly Health System Implementation in Outpatient Settings: A Systematic Review

The Age-Friendly Health System (AFHS) movement has spread widely in recent years, with nearly 5000 healthcare organizations across the country recognized as Age-Friendly. Despite this broad recognition, there is little focus on how AFHS are implemented and the impact of implementation. The objectives of this study were to describe the strategies employed to support AFHS implementation in outpatient settings and to identify the measures used to evaluate implementation and effectiveness. We conducted a systematic review of literature from multiple databases spanning 2015 to March 2024, identified eligible studies using predefined inclusion/exclusion criteria, and extracted key data (eg, study design, study population, implementation strategies, outcomes/measures). We identified ten eligible studies from primary care clinics (N = 8), convenient care clinics (N = 1) and a cancer center (N = 1). The studies employed over 65 implementation strategies and 98 outcomes or measures. The vast majority of measures mapped to components of the 4Ms (Mobility, Mentation, Medication, What Matters), with up to ten measures per M category. Five of ten studies had reporting discrepancies and four did not fully define outcomes. The ten included studies serve as clear examples for the need for more evidence to support AFHS implementation in outpatient settings. Existing research lacks strategy specification and standardization of measures. We present gaps and opportunities to advance from AFHS "recognition" to impact.

A public health/hospital partnership to improve Emergency Department transitions of care for vulnerable older adults

BACKGROUND

Community-dwelling older adults are at high risk for unmet social service needs. We describe a novel partnership embedding county services case managers in the Emergency Department (ED) to connect older adults to community services alongside their medical care.

METHODS

Setting: A medium-sized urban ED with 55,000 patient visits a year.

INTERVENTION

Case managers from the Franklin County, Ohio Office on Aging (OA) were embedded within the ED. The OA team worked with the ED social work team to identify community-dwelling older patients, perform an in-person intake assessment, and initiate needed community services (including home-delivered meals, emergency response systems, house repairs, and transportation). Program logic model and development are reported in detail.

RESULTS

From June to December 2023, there were 7284 ED visits for adults ≥60 years old. Referrals to the OA case manager ranged from 1 to 13 per day. The OA case managers performed 252 full intake assessments on unique patients. The population was 51% men. Only 11% (n = 28) were currently connected to OA services, and of those already connected 29% (n = 8) needed increased services. Of the remaining unconnected patients (n = 224), 8% (n = 20) were not county residents and the OA team connected them with other county OAs. Half 53% (n = 120) were accepting of services and had services from the OA or other community health programs initiated during the ED visit. The OA team made three new Adult Protective Services referrals and one referral to the long-term care ombudsman. The program did not increase ED length of stay or hospital admission rates.

CONCLUSIONS

Embedding county service enrollment within a community ED is a cost neutral intervention that reached a population without previous services. Future plans include expansion of the program and evaluation of the program's ability to detect elder mistreatment and self-neglect.

Applications of Behavioral Economics and Neuroeconomics in Mental Health

Objective: The integration of behavioral economics and neuroeconomics into mental health offers innovative perspectives on understanding and addressing psychological disorders. This overview aims to synthesize current knowledge and explore the implications of these interdisciplinary approaches in the context of mental health. Method : In this narrative review, we summarized the current evidence regarding the applications of behavioral economics and neuroeconomics approaches in the field of mental health. Results: Behavioral economics and neuroeconomics provide valuable insights into the cognitive and emotional processes underlying mental health disorders, such as irrational decision-making, impulsivity, and self-control issues. Concepts such as loss aversion, temporal discounting, and framing effects inform the development of innovative interventions and policy initiatives. Behavioral economic interventions, including nudges, incentives, and commitment devices, show promise in promoting treatment adherence, reducing risky behaviors, and enhancing mental well-being. Neuroeconomics contributes by identifying neural markers predictive of treatment response and relapse risk, paving the way for personalized treatment approaches. Conclusion: The integration of behavioral economics and neuroeconomics into mental health research and practice holds significant potential for improving the understanding of psychological disorders and developing more effective, personalized interventions. Further research is needed to elucidate the mechanisms of action, optimize intervention strategies, and address ethical considerations associated with these approaches in mental health settings.

Within-person relationships between catastrophizing and pain intensity during a mind-body intervention to prevent persistent pain and disability after acute traumatic orthopedic injury

Interventions aimed at preventing chronic pain after acute traumatic injury have significant potential to reduce healthcare expenditures and improve quality of life for millions of individuals. Given recent development of such interventions, limited research has examined mechanisms of change using repeated measures (e.g., session-by-session assessments). This study examines within-person relationships between pain catastrophizing and intensity during and after a four-session mind-body intervention for individuals with acute traumatic orthopedic injury (N = 76, T = 445). Random intercept cross-lagged panel models were used to examine within-person autoregressive, contemporaneous, and cross-lagged effects between pain catastrophizing and pain intensity, after accounting for stable between-person differences. Our primary hypothesis that improvements in catastrophizing would be associated with subsequent reductions in pain intensity was partially supported by a significant within-person cross-lagged effect between catastrophizing at post-test and pain with activity reported at three-month follow-up (β = 0.421, SE = 0.099, p < .001). Improvement in catastrophizing was also associated with same-session improvement in pain intensity midway through the intervention. Importantly, bidirectional within-person analyses allowed us to rule out the possibility that improvements in pain were responsible for subsequent improvements in catastrophizing, but not vice versa. Together, these findings suggest improvements in catastrophizing during psychosocial intervention may prevent transition from acute to chronic pain after injury. Future research with larger between-person sample sizes, more frequent within-person assessment, and comparable control group data is necessary to facilitate greater understanding of psychosocial mechanisms for preventing chronic pain after injury. PERSPECTIVE: This study examines within-person relationships between pain catastrophizing and intensity during and after a four-session mind-body intervention to prevent persistent pain after acute traumatic orthopedic injury. Improved catastrophizing at post-test was associated with reduced pain with activity at three-month follow-up. Within-person analyses enhance understanding of psychosocial mechanisms for preventing chronic pain after injury.

An audit and feedback-based intervention to improve diabetes management in the year after transfer to adult type 1 diabetes care: A multi-center quasi-experimental study

AIM

To test whether an audit and feedback-based intervention improved HbA1c 12 months after transfer to type 1 diabetes adult care.

METHODS

Multi-centre, quasi-experimental pre-post study of an AF-based intervention targeting paediatric diabetes teams, which encouraged the implementation of an evidence-informed structured transition process at five paediatric diabetes centres in Ontario, Canada. Participants entered the study at their final paediatric visit. A parallel control cohort was ascertained using population-based administrative datasets. The primary outcome was HbA1c 12 months after transfer. The main exposure was the study period: pre-implementation (June 2018-May 2019); early-implementation (June 2019-September 2020); and late-implementation (October 2020-September 2021). Multivariable linear regression models were fit separately in each cohort.

RESULTS

There were 449 and 2844 individuals in the intervention and control cohorts, respectively. Twelve months after transfer, participants in the late-implementation intervention cohort had an HbA1c that was, on average, 0.41% lower than participants in the pre-implementation period (p = 0.016). Among the control cohort, there was no significant difference in the HbA1c 12 months after transfer between study periods.

CONCLUSIONS

We found an effect of the intervention on glycaemic management one year following transfer to adult care. Future work will focus on refining and testing the effectiveness of the intervention in an expanded number of study sites and in collaboration with adult diabetes care providers.

Virtual reality on perioperative anxiety in pediatric patients: A narrative review

Preoperative anxiety is a common response to stress specifically in the pediatric population exhibiting heightened susceptibility to it. High anxiety levels can negatively impact the quality of anesthesia, increase analgesia requirements, and result in significant postoperative pain. The present review synthesizes recent literature regarding virtual reality (VR)'s efficacy in mitigating preoperative anxiety in the pediatric population. Virtual reality is a nonpharmacological intervention that alleviates pain and preoperative anxiety through cognitive distraction, redirecting patients' focus away from discomfort. Neurophysiologically, VR engages the prefrontal cortex, influences pain pathways, and reduces pain-related activity in the thalamus, insula, anterior cingulate cortex, and primary and secondary somatosensory cortices. Evidence indicates that VR is more effective in reducing anxiety compared to other nonpharmacological strategies, particularly benefiting younger children, who tend to exhibit higher levels of engagement in magical thinking compared to adolescents. Virtual reality presents numerous clinical applications, including facilitating postsurgical recovery, assisting in physiotherapy for neuromuscular disorders, and providing nonpharmaceutical analgesia. However, its integration into healthcare faces several challenges, such as the high costs of acquiring and maintaining the equipment, particularly in resource-limited settings. Moreover, the limited number of studies examining VR exposure with small nonrepresentative sample sizes further constrains its recommendation as an anxiety-reduction technique. Despite its limitations, substantial evidence suggests that VR has the potential to alleviate preoperative anxiety and mitigate the psychological responses of pediatric patients. Standardized research protocols featuring larger sample sizes and expanded access to VR across various levels of care are necessary.

Implementation of Site-Specific Hepatitis C Virus Treatment Workflows for Vulnerable, High-Risk Populations: A Prospective Single-Arm Trial

INTRODUCTION

Hepatitis C virus (HCV) treatment with pan-genotypic direct acting antivirals is highly effective, given an evidence-based simplified treatment algorithm. Yet access to treatment is limited among vulnerable populations.

OBJECTIVE

We assessed the effectiveness of site-specific HCV treatment workflows on HCV care for vulnerable populations in Austin, Texas.

METHODS

Patients diagnosed with chronic hepatitis C enrolled in care at a study site were eligible for this prospective, single-arm clinical trial. We assessed the proportion of participants that: (1) were prescribed treatment, (2) initiated treatment, (3) completed treatment, (4) were assessed for cure, and (5) achieved cure. We also evaluated implementation using the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework.

RESULTS

Of 62 participants, 89% had ever experienced homelessness and 94% had ever used drugs. An estimated 66% (95% CrI, 42%-84%) were prescribed treatment and 49% (95% CrI, 26%-70%) initiated treatment. An estimated 38% (95% CrI, 20%-58%) completed treatment, 14% (95% CrI, 4%-44%) were assessed for cure, and 10% (95% CrI, 2%-35%) achieved cure.

CONCLUSIONS

We identified gaps along the HCV care cascade between: (1) enrolled to prescribed treatment and (2) completed treatment to assessed for cure. Site-specific HCV treatment workflows were insufficient to engage participants in care and avoid treatment delays. Novel approaches are needed and these may include patient outreach, patient navigation, test-and-treat protocols, and removing financial or payor barriers to medication access.

TRIAL REGISTRATION

Registered on ClinicalTrials.gov on July, 14, 2022. Identifier: NCT05460130. https://clinicaltrials.gov/ct2/show/NCT05460130.

Not getting better but not getting worse: A cluster randomized controlled pilot trial of a leadership implementation strategy

Background

Implementation of evidence-based practices (EBPs) in schools is fraught with challenges. Even when EBPs are initiated, deterioration of implementation efforts often hinders their long-term success. School leadership behaviors can influence teachers' EBP implementation. Our study tested an implementation strategy called Helping Educational Leaders Mobilize Evidence (HELM), adapted from the Leadership and Organizational Change for Implementation strategy, to enhance EBP implementation through improvements in school leadership teams' implementation leadership and climate to buffer against the deterioration of implementation efforts. This study explores the impact of HELM on theorized mechanisms of change (i.e., implementation leadership, climate), educator-level factors (i.e., implementation citizenship), and implementation outcomes (i.e., fidelity, initiative stability).

Method

One school district and 10 schools in Washington participated. Five of the schools were randomized to receive the HELM strategy and the remaining five schools received an alternative leadership training as an implementation attention control. Teachers at every school (n = 341) received training for an EBP called Positive Greetings at the Door that has been previously demonstrated to reduce student behavior problems. Principals and Assistant Principals (n = 18) received the HELM strategy or alternative leadership training. Three district Administrators also participated in HELM as part of the Organizational Strategy Development meetings.

Results

HELM significantly slowed the average decline of implementation leadership (perseverant leadership and communication), three dimensions of implementation climate (recognition, rewards, and existing supports) and total implementation climate, and one dimension of implementation citizenship (keeping informed). No significant effects were found with regard to implementation outcomes (i.e., fidelity, initiative stability).

Conclusions

HELM shows promise in buffering the deterioration of EBP implementation efforts in schools. HELM positively influenced implementation leadership and climate, which are the hypothesized mechanisms for promoting successful long-term implementation efforts. An appropriately powered trial is needed to determine the efficacy of HELM in the future.Name of the registry: clinicaltrials.govTrial registration number: NCT06340074Date of registration: March 29, 2024. Retrospectively registeredURL of trial registry record: https://clinicaltrials.gov/study/NCT06340074?intr=helm&rank=.

Planning for implementation success: insights from conducting an implementation needs assessment

AIM

The aim of this paper is to provide insights into conducting an implementation needs assessment using a case example in a less-research-intensive setting.

DESIGN AND METHODS

In the case example, an implementation needs assessment was conducted, including (1) an environmental scan of the organization's website and preliminary discussions with key informants to learn about the implementation context, and (2) a formal analysis of the evidence-practice gap (use of sedation interruptions) deploying a chart audit methodology using legal electronic reports.

RESULTS

Our needs assessment was conducted over 5 months and demonstrated how environmental scans reveal valuable information that can inform the evidence-practice gap analysis. A well-designed gap analysis, using suitable indicators of best practice, can reveal compliance rates with local protocol recommendations, even with a small sample size. In our case, compliance with the prescribed practices for sedation interruptions ranged from 65% (n=53) to as high as 84% (n=69).

CONCLUSIONS

Implementation needs assessments provide valuable information that can inform implementation planning. Such assessments should include an environmental scan to understand the local context and identify both current recommended best practices and local best practices for the intervention of interest. When addressing an evidence-practice gap, analyses should quantify the difference between local practice and desired best practice.

IMPACT

The insights gained from the case example presented in this paper are likely transferrable to implementation research or studies conducted in similar, less-research-intensive settings.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A257.

Addressing Barriers to Implementing and Scaling PrEP in Carceral Settings: Applying Insights From Implementation Science

INTRODUCTION

Within the United States, individuals experiencing incarceration are at higher risk for HIV acquisition than the general population, yet may face additional difficulty engaging in HIV prevention clinical services. HIV preexposure prophylaxis (PrEP) is an effective approach to preventing HIV transmission, and the Centers for Disease Control recommends that PrEP be offered in carceral settings, particularly during the vulnerable community reentry period. However, there have been few efforts to scale PrEP in this setting.

METHODS

Based on our experience implementing PrEP in Rhode Island's state carceral system, we have identified potential approaches to overcoming barriers to PrEP use in this unique practice environment by using the implementation research logic model. We then evaluated specific implementation determinants and barriers as well as strategies used to overcome those barriers to effectively scale PrEP in this setting.

RESULTS

We developed a "toolkit," or 14-step guide, for others in the field to use for implementing PrEP in carceral settings, including the development and use of clinical protocols and community linkage strategies.

DISCUSSION

Our experiences with barriers in the carceral setting, identifying and leveraging implementation strategies, allowed us to develop a "toolkit" to guide other PrEP implementation projects in carceral settings. We encourage others to scale-out our work to other carceral settings to better reach and engage a group of individuals both at elevated risk for HIV and currently underserved by HIV prevention strategies, including PrEP.

Psychotherapists' Experience with In-Session Use of Routine Outcome Monitoring: A Qualitative Meta-analysis

Routine outcome monitoring (ROM) has become an increasingly utilized tool in therapeutic practice that has the potential to improve therapy outcomes. This study aimed to synthesize the findings of existing qualitative studies investigating how clinicians use ROM in their work with clients. A systematic search of qualitative studies on clinicians' experience with the use of ROM in mental health services was conducted via PsycInfo, PsycArticles, Medline, Web of Science, and Scopus databases. Qualitative meta-analysis was used to synthesize the finding of the primary studies. Forty-seven studies met the inclusion criteria. The analysis resulted in 21 meta-categories organized into six clusters, namely (1) obtaining clinically relevant information, (2) adapting treatment, (3) facilitating communication, (4) enhancing the therapeutic relationship, (5) facilitating change in clients, and (6) personalized usage of ROM. The meta-analysis revealed that clinicians utilized ROM in diverse ways, including both informational and communicational functions. From the clinicians' perspective, ROM was an element that, on the one hand, introduced additional structure and standardization in treatment and, on the other hand, allowed for greater flexibility and tailoring of treatment.

Children and providers' perspectives on once-weekly rifapentine and isoniazid TB preventive therapy

BACKGROUND

TB preventive treatment (TPT) prevents the development of TB disease in individuals at risk of progression from infection to disease. However, implementation of TPT for children is poor in most high-burden settings. The long duration and pill burden of the 6-month once-daily isoniazid regimen (6H) pose significant barriers to completion. We aimed to understand children's, caregivers', and healthcare providers' experiences of the 12-week once-weekly rifapentine and isoniazid (3HP) regimen using a dispersible tablet formulation in South Africa.

METHODS

Serial, in-depth qualitative interviews with 20 child-caregiver dyads, including 5 children living with HIV (CLWH) and 9 healthcare providers across two study sites implementing a pharmacokinetic and safety trial of 3HP, were analysed deductively.

RESULTS

Of those with experience using both 3HP and 6H, caregivers and healthcare providers preferred 3HP, and study participants reported that the 3HP formulation was more palatable and easier to prepare and administer. Caregivers and healthcare providers were concerned about optimally integrating 3HP into routine care, primarily due to its once-weekly administration. Children with HIV preferred the once-daily 6H regimen for its ease of use with their daily antiretroviral therapy.

CONCLUSIONS

3HP reduced the administration burden for children and their caregivers. Once weekly, 3HP dosing will require education and adherence support to ensure completion.

Comparing 2 Training Modalities Supporting the Adoption of the Safe Environment for Every Kid Approach in Pediatric Primary Care

OBJECTIVE

To compare the impact of 2 common continuing medical education training modalities-independent online training (IND) and a Maintenance of Certification-4 (MOC) activity-on primary care professionals' (PCPs') thinking and practice behavior regarding the Safe Environment for Every Kid (SEEK) approach. This was part of an implementation science study scaling up the evidence-based practice, SEEK.

METHODS

This is a longitudinal, multisite, mixed methods, cluster randomized controlled trial comparing 21 pediatric primary care practices across the United States randomized to 1 of 2 training modalities. Two hundred ten PCPs completed surveys up to 4 times over a 2-year period to assess their thinking and practice regarding SEEK; a subset was interviewed up to 3 times.

RESULTS

Training led to significant and sustained improvements in PCPs' thinking and behavior related to SEEK, with no significant differences between the IND and MOC groups. PCPs mostly viewed their training positively, but several described shortcomings. PCP characteristics, such as age and sex, did not moderate the impact of the training, nor did the presence of a behavioral health professional.

CONCLUSIONS

The lack of significant differences between the training modalities favors the simpler IND modality. This was despite the MOC training employing key principles of adult education. Of note, MOC-4 credits are required for pediatric board certification. More research is needed to optimize continuing medical education and tailor approaches for different learners.

CLINICAL TRIAL REGISTRY AND DATA SHARING STATEMENT

SEEK: Dissemination and Implementation, NCT03642327: https://clinicaltrials.gov/ct2/show/NCT03642327.

Pre-implementation determinants for digital mental health integration in Chicago pediatric primary care

OBJECTIVE

Pediatric primary care (PPC) is a common treatment site for pediatric mental health, but it is currently unable to meet the needs of all teen patients, particularly those with minoritized identities and/or marginalized experiences. Digital mental health (DMH) low-intensity treatments (LITs) can increase mental health screening and care capacity in PPC, but how this is done successfully without burdening providers, patients, or families is unclear. This paper presents a pre-implementation study aimed at understanding the implementation context (PPCs in Chicago, IL) for a specific DMH LIT.

METHOD

Using a mixed-methods design, quantitative data from an online survey of providers assessed current DMH practices in PPC, and qualitative interviews with Pediatricians and Pediatric Psychologists examined implementation determinants for a specific DMH LIT. Quantitative data were analyzed using descriptive statistics, and interviews were analyzed using rapid qualitative assessment.

RESULTS

Survey reports (n = 105) and interviews (n = 6) indicated low current use of DMH. Providers in PPC clinics voiced multiple reasons for low usage and low perceived feasibility, including: Consolidated Framework for Implementation Research (CFIR) Inner Setting Domain (PPC clinic workflow, responsibility and ethical considerations, patient privacy and confidentiality), CFIR Outer Setting Domain (hospital and healthcare system factors), CFIR Innovation Domain (DMH design), and a cross-cutting theme of safety.

CONCLUSIONS

Provider-reported low feasibility for integrating DMH in PPC is a call to action to partner with interdisciplinary colleagues and identify how such settings can ethically and seamlessly deliver digital evidence-based and accessible screening and care prior to implementation.

Men's influence of maternal substance use before, during, and after pregnancy: A qualitative study of men with criminal-legal involvement

BACKGROUND

While the adverse effects of substance use during pregnancy are well-established, the impact men with criminal-legal involvement who use substances have on their partner's substance-using behaviors is not well characterized. We aim to understand men's experiences and perspectives about how their substance use impacts romantic partner substance use in the preconception period, before a potential or actual pregnancy.

METHODS

We conducted semi-structured interviews with men residing in a transition center in the Midwestern US with a substance use disorder (SUD) who partnered with women. Interview questions were informed by the Health Belief Model (HBM) and included questions about perceived susceptibility, severity, benefits, barriers, cues to action, and self-efficacy in relation to substance use and pregnancy. Participants were asked about desired SUD interventions. Transcripts were analyzed using a modified grounded theory approach.

FINDINGS

Thirty participants were interviewed (mean age=37, SD=10.3). Major themes were mapped onto HBM constructs: (1) Partners did not consider the chance of pregnancy while using together; (2) using together can escalate use before/during pregnancy; (3) quitting can strengthen relationships; (4) lack of preconception health knowledge inhibits quitting; (5) having a pregnant partner may promote quitting; and (6) knowledge of potential negative outcomes increases confidence in quitting.

CONCLUSION

Men in carceral settings face multi-factorial barriers to substance use cessation and have differing perspectives on the impact of their use on their partner in relation to potential or actual pregnancy. Clinicians should consider interpersonal relationship factors that may impede or promote substance use when caring for people with SUD.

Determinants of Familiarity and Experience with HIV Pre-Exposure Prophylaxis in Primary Care Providers in Ontario, Canada

BACKGROUND

Despite increased access to HIV pre-exposure prophylaxis (PrEP) in Canada, familiarity and experience among primary care providers (PCPs)-including family doctors and those working with key populations-remains limited. To understand the barriers and facilitators of PrEP familiarity and experience, we conducted a situational analysis in PCPs in sub-urban and rural Ontario.

METHODS

We surveyed a non-probabilistic sample of PCPs using an online questionnaire, designed with the Consolidated Framework for Implementation Research (CFIR). Poisson regressions with robust variance were used to assess the relationship between CFIR domains, sociodemographic, and practice characteristics on both PrEP familiarity and experience.

RESULTS

A total of 54 PCPs participated (6% response rate), comprising 80% physicians and 20% nurses. Nearly 30% of the sample worked with key populations, including sexual health clinics and community care centers, 18% of respondents reported high familiarity with PrEP, and 44% reported PrEP experience (referred, started a conversation, or prescribed). PrEP familiarity and experience were associated with working in an organization serving key populations, working with gender minorities, and having colleagues providing PrEP. Providers with a positive perception of PrEP and its necessity for populations at risk were more likely to have PrEP-related experience. Higher familiarity and experience were reported by PCPs with specific clinical skills related to PrEP, and with the perception that PrEP was compatible with their practice as primary provider.

CONCLUSIONS

Our findings suggest that organizational support, and additional training and education would facilitate PrEP provision by PCPs in suburban/rural Ontario.

Dose-Response Effects of MittEcho, a Measurement Feedback System, in an Indicated Mental Health Intervention for Children in Municipal and School Services in Norway

Including routine client feedback can increase the effectiveness of mental health interventions for children, especially when implemented as intended. Rate of implementation, or dose, of such feedback interventions has been shown to moderate results in some studies. Variation in implementation and use of client feedback may also contribute to the mixed results observed within the feedback literature. This study evaluates dose-response associations of client feedback using a novel Measurement Feedback System (MFS) within an indicated group intervention. The primary aim was to determine whether the rate of MFS implementation predicts symptom reduction in anxiety and depression among school-aged children. The secondary aim was to assess whether the rate of MFS implementation influences children's satisfaction with the group intervention or their dropout rates. Data were collected via a randomized factorial study (clinicaltrials.gov NCT04263558) across 58 primary schools in Norway. Children aged 8 to 12 years (N = 701) participated in a group-based, transdiagnostic intervention targeting elevated symptoms of anxiety or depression. Half of the child groups also received the feedback intervention using the MittEcho MFS. Group leaders (N = 83), recruited locally, facilitated the interventions. The MFS dose was measured using the Implementation Index, which combines the use of MFS by both children and providers (group leaders) into a single dose variable. Results showed no significant additional effect of dose of MFS on change in depression or anxiety scores, on user satisfaction with the intervention or on intervention dropout. The discussion addresses potential reasons for these non-significant findings and implications for MFS implementation in preventive, group-based interventions in school settings.

Usability of a mobile app for suicide risk awareness in South Korea

Background

Suicide rates have significantly increased in South Korea, yet many individuals lack adequate support. Barriers such as reluctance to seek mental health help and fear of social stigma contribute to this gap. A mobile app focused on suicide risk awareness could provide accessible support, though none are currently available for public use in South Korea. This study conducted a usability test on a newly developed suicide risk awareness app using a mixed methods approach.

Methods

Thirty-eight students from a large university in South Korea participated in the study, with 19 in a high-risk suicide group and 19 in a nonrisk suicide group. After using the app for 2 weeks, all participants completed an online usability survey, and 19 students took part in individual interviews.

Results

Independent samples t-tests showed that participants, regardless of risk group, rated the app positively for ease of use, accessibility, design, perceived learning, and satisfaction. Regression analysis identified perceived learning as the strongest predictor of satisfaction, followed by ease of use. The qualitative analysis highlighted areas for improvement, including providing direct and guided feedback on suicide risk.

Conclusion

The study demonstrated the potential of a mobile app to enhance suicide risk awareness among young adults in South Korea. Moreover, user engagement with the app can be improved by ensuring confidentiality and fostering perceived learning.

Training and Technical Assistance Increase the Fidelity of Implementation of a Universal Prevention Initiative in Rural Schools: Results from a 3-Year Cluster-Randomized Trial

The need for well-implemented evidence-based interventions (EBIs) for the prevention of behavioral issues among children and adolescents is substantial. In rural areas, the need often matches or surpasses that of urban areas. Schools have a wide reach for prevention-focused EBIs. However, implementation in rural schools is often hindered by limited resources and capacity. Rural School Support Strategies (RS3) are a bundle of implementation supports that address implementation challenges in rural settings. They include providing additional leadership and coaching training, individualized technical assistance (mostly virtual), and monthly meetings of a virtual learning collaborative. A cluster-randomized Hybrid Type 3 implementation-effectiveness trial tested RS3 for implementing school-wide positive behavioral interventions and supports (PBIS), a universal prevention approach to improving student behavior, academic outcomes, and school climate. Forty rural schools received a multi-day training on PBIS each summer for 3 years. Half were randomized to also receive RS3 support. Linear and logistic regression models examined the effect of treatment condition and dosage of support on implementation fidelity for Tier 1 (universal) PBIS. Condition and dosage (number of hours) of support increased the odds of schools achieving the 70% threshold for adequate implementation fidelity. In the first year, the higher dosage of technical assistance events increased the likelihood of schools reaching fidelity, whereas later in the trial, the higher dosage of attendance at the virtual learning collaborative sessions yielded significant improvements in fidelity. Implications for accelerating the implementation of universal prevention initiatives in schools-particularly in rural settings-are discussed. This study was prospectively registered on ClinicalTrials.gov (NCT03736395), on November 9, 2018.

HIV testing services and HIV self-testing programming within emergency care in Kenya: a qualitative study of healthcare personnel to inform enhanced service delivery approaches

In Kenya, persons insufficiently engaged in HIV Testing Services (HTS) are often treated in emergency departments (ED). There are limited data from healthcare workers on ED-HTS. A qualitative study was completed to understand challenges and facilitators for ED-HTS and HIV self-testing (HIVST). Data were collected via six focus groups of healthcare workers. Data were inductively analyzed and mapped to the Capability-Opportunity-Motivation Behavioral Model. Focus groups were completed with 49 healthcare workers: 18 nurses, 15 HIV counselors, 10 physicians and 6 administrators. HTS challenges included staff burdens, resources access, deficiencies in systems integration and illness severity. HTS facilitators included education of healthcare workers and patients, services coordination, and specific follow-up processes. HIVST challenges included accuracy concerns, follow-up barriers and psychosocial risks. HIVST facilitators were patient autonomy and confidentiality, resource utilization and ability to reach higher-risk persons. Mapping to the Capability-Opportunity-Motivation Behavioral Model interventions within the domains of knowledge, decision processes, environmental aspects, social influences and professional identities could support enhanced ED-HTS with integrated HIVST delivery. This study provided insights into challenges and facilitators on ED-HTS and identifies pragmatic approaches to improve healthcare workers' behaviors and abilities to provide services to persons already in contact with healthcare.