Mixed methods research: expanding the evidence base

Systematic review: Need for high-quality research on occupational therapy for children with intellectual disability

BACKGROUND

Enabling participation in everyday life and supporting development are essential goals in occupational therapy of children and young people with intellectual disabilities (ID).

OBJECTIVE

To gather and evaluate evidence of the effectiveness of occupational therapy interventions for children with ID in terms of participation in everyday life.

MATERIAL AND METHODS

A literature search conducted using electronic databases (CINAHL, Cochrane Library, PubMed and EMBASE) from January 2000 to May 2020. Methodological quality was assessed using the Joanna Briggs Institute critical appraisal tools. Quality of evidence was critically appraised with the GRADE.

RESULTS

The search yielded 4741 records, of which 15 studies met the inclusion criteria: 3 randomized controlled trials, 3 case-control studies, 2 case series and 7 case reports. The studies were diverse in quality. The evidence is inconclusive because of the limited amount of methodologically robust studies.

CONCLUSIONS AND SIGNIFICANCE

Results support the notion that occupational therapy in daily environments for children with ID may enhances participation in everyday activities. Further research with appropriate study designs and outcome measurements is needed. Although the research evidence was limited, the results encourage focussing on occupational therapy for children with ID to enhance participation in school and home environments.

Potential advantages of combining randomized controlled trials with qualitative research in mood and anxiety disorders - A systematic review

INTRODUCTION

Most randomized controlled trials (RCTs) of mood and anxiety disorders employ solely quantitative methods. Supplementing quantitative data with qualitative methods, a so-called mixed-method approach, would seem useful, however this area has not been rigorously reviewed. We undertook a systematic review of RCTs of mood and anxiety disorders that employed concurrent quantitative data collection and qualitative methods exploring the participants' perspective, with the aim of 1. determining the number of such studies, 2. describing study characteristics, and 3. identifying potential advantages of a mixed-method approach.

METHODS

Following PRISMA guidelines, a systematic literature search for RCTs of mood and anxiety disorders, concurrently applying quantitative and qualitative methods, was conducted using EMBASE, PsycINFO and Pubmed, from their inception to February 2021. Categories of potential advantages of this mixed method approach were developed.

RESULTS

A total of 45 RCTs were included. The qualitative components typically included 10-40 participants, mostly consisting of interviews after the intervention. The majority of papers did not state a specific rationale for using a mixed method approach. Four categories of advantages emerged: 1. determine acceptability/feasibility, 2. investigate efficacy, 3. inform implementation in clinical practice and 4. generate new hypotheses based on the combination of quantitative and qualitative data.

LIMITATIONS

Lack of cross-referencing and consistent terminology challenged identification of relevant publications.

CONCLUSION

There are a number of potential advantages of applying mixed method approaches in RCTs within psychiatric research. Intentional consideration of such advantages early in trial design may increase the likelihood of gaining added value.

Farmers' attitudes towards agricultural plastics - Management and disposal, awareness and perceptions of the environmental impacts

The amount of plastic waste resulting from agricultural practices is increasing and this trend is expected to continue. Although plastics are essential for certain farming tasks, their impact on the environment is becoming a major issue of concern. Mismanaged larger plastics can disintegrate into microplastics and make their way into soils, surface and groundwater sources. Microplastics are extremely persistent and have the potential to facilitate the transfer of contaminants through the environment, potentially affecting terrestrial and aquatic wildlife. A descriptive survey was conducted on a sample of farmers (n = 430) in Ireland to assess their attitudes on agricultural plastic waste management and their awareness and perceptions of the impacts of microplastics and plastics on the environment. This study found that most farmers (88.2%) are concerned about the amount of plastic waste generated by farming activities. Agricultural plastic disposal methods vary and recycling rates mostly depend on the type of plastic, the cost of recycling and access to facilities. Most farmers view agricultural plastics negatively due to their impact on the environment but also because of the monetary and logistical burdens associated with them. Farmers were relatively aware of microplastics (57.5%), but overall more farmers felt they knew more about plastic pollution than microplastic pollution and these issues in aquatic systems. This was also evident when it came to their perception of the risks plastics pose on the environment with more farmers believing that aquatic environments are at greater risk than the terrestrial environments. Future research efforts must focus on plastic and microplastic pollutions in soils to inform policy-makers and to create greater public awareness. In addition to this, several developments are needed in a collective effort by governments, policy-makers and other stakeholders to reduce plastic and microplastic problems in agriculture.

The impact of learning styles on attitudes to interprofessional learning among nursing students: a longitudinal mixed methods study

BACKGROUND

A functional interprofessional teamwork improves collaborative patient-centred care. Participation in interprofessional education promotes cooperation after graduation. Individuals tend to use different approaches to learning depending on their individual preferences. The purpose of this study was to explore nursing students' experiences of professional development with a focus on the relationship between attitudes to interprofessional learning and learning styles.

METHODS

A longitudinal parallel mixed-methods design. The study was carried out at a Swedish three-year nursing program from August 2015 to January 2020. On enrolment, thirty-four students self-assessed their attitudes to interprofessional learning according to the Readiness for Interprofessional Learning Scale, and their learning style according to Kolbs' Learning Style Inventory. In the final semester the students participated in an interview focusing on their experiences and perceptions of teamwork and they self-assessed their attitudes to interprofessional learning again.

RESULTS

Our findings indicated that 64.7% had a predominantly concrete learning style and 35.3% had a predominantly reflective learning style. No significant relationship with internal consistency reliability was identified among the participants between attitudes to interprofessional learning and learning styles. The content analysis resulted in four main categories: Amazing when it's functional; Deepened insight of care; Increased quality of care; Understanding own profession which were summarized in the theme: Well-functioning teams improve patients' outcome and working environment.

CONCLUSION

The students' attitudes to interprofessional learning were positive and it was considered as an opportunity to participate in interprofessional cooperation during internship. Transformative learning is a useful strategy in fostering interprofessional relationships due to the interdependence of various professions in interprofessional teams. When students are guided to use reflection to develop new perspectives and meaning structures, they acquire emotional and rational skills beneficial for interprofessional cooperation.

[Experiences and support needs of lifestyle professionals in the use of digital coaching tools for clients with overweight]

Introduction

In the Netherlands, half of the adult population is overweight. Combined Lifestyle Interventions guide overweight clients towards a healthy lifestyle. In addition to the face-to face sessions with clients, lifestyle professionals can use digital coaching tools to guide their clients remotely. In practice it appears that the digital applications are not fully used. To stimulate the use of digital technology, insight is needed into the experiences and support needs of lifestyle professionals.

Method

Data about the use, wishes and support needs regarding the use of digital coaching tools among lifestyle professionals were collected by a questionnaire and two focus groups. The results of the questionnaires were analyzed descriptively and the focus groups were analyzed thematically.

Results

Seventy-nine lifestyle professionals completed the questionnaire. Ten lifestyle professionals participated in a focus group. Both methods showed that professionals have gained experience with video communication, apps and online information. Lifestyle professionals mention that these digital coaching tools support the self-reliance of clients. Online group sessions are perceived as less effective than face-to-face group sessions, because of the lack of interaction between clients. Lifestyle professionals also experience practical barriers in using digital coaching tools. To stimulate the use of digital coaching tools, they need an exchange of experience with colleagues, training and instruction on how to use these tools.

Conclusion

Lifestyle professionals consider digital coaching tools to be an added value to individual coaching. They see opportunities for wider use in the future when practical barriers are overcome, and exchange of experience and training are facilitated.

Promoting System Thinking and Professionalism Through Simulated Hospital Experiences for Nursing and Clinical Laboratory Science Students

ABSTRACT

A simulation laboratory was developed for prelicensure nursing and undergraduate clinical laboratory science students using scripted patient cases with laboratory test results. The experience was guided by TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety). Participants ( n = 66) completed the modified Interprofessional Professionalism Assessment pre- and postsimulation. Journal reflections provided qualitative data. All aspects of interprofessional professionalism increased after the simulation; the most significant gain was confidence in working with other health care professionals. Analysis of journal themes indicated the students perceived increased communication and collaboration skills concerning patient care and safety.

Maternal perceptions of human milk expression output: An experimental design using photographs of milk

BACKGROUND

The widespread use of breast pumps in the United States is a recent phenomenon that is reshaping how individuals understand and perceive lactation. In the 1990s, adequacy of milk supply was primarily measured indirectly by infant weight gain and/or diapers; now >95% of all lactating persons in the United States use breast pumps and are seeing their milk regularly. How seeing milk impacts the perception of lactation sufficiency is an important area of research. Research aim/question: To understand personal and intersubjective influences of seeing expressed human milk on perceptions of milk supply among participants who express milk for their infants.

METHODS

We surveyed 805 lactating participants from the United States about their pumping practices using an online survey. Participants described pumping practices, milk output, and beliefs. They were then randomized to view one of three photographs of expressed milk (<2 oz, 4 oz, >6oz) and asked to imagine they had just pumped that amount and provide a written response; this created 4 exposure groups (2 increase and 2 decrease) and a control group (no difference).

RESULTS

Participants randomized to a higher volume reported more positive feelings and used the terms "good", "great", and "accomplished" to describe emotional responses to output. Participants randomized to lower milk volumes reported more feelings of "bad" or "depressed." A subset of participants reported feeling "annoyed" about small volumes of milk.

CONCLUSIONS

Participants in this study were very conscious of the volume of milk pumped each session; both increases and decreases were associated with emotional responses that could contribute to decisions about pumping practices, perceived milk supply, and lactation duration.

Gender Disparities in Physician Assistant Educator Promotion and Compensation: A Mixed Methods Approach

INTRODUCTION

The gender wage gap is well documented in many industries. A disparity in salary between female and male physician assistant (PA) educators has been demonstrated, but disparities in academic rank have not been shown. The purpose of this study was to re-examine gender disparities in compensation to PA educators and to explore whether gender-based disparities exist in promotion to higher academic rank in this field.

METHODS

An explanatory sequential mixed-methods design was used to determine differences in salary and rank by gender. PA Education Association Faculty and Directors Survey data from 2014, 2017, and 2019 were analyzed. A focus group was conducted to explain the findings and understand the barriers to promotion for female faculty.

RESULTS

Female PA faculty members earn $7573 less than their male colleagues when controlling for all other variables. Female faculty members have an increased likelihood (RR 1.150) for being in early career stage versus late career stage. Obtaining a doctoral degree decreased the risk for being in an early career stage (RR 0.567) with men twice as likely to have a doctoral degree as women.

DISCUSSION

Rank and salary disparities exist in PA faculty by gender. Female faculty are less likely to hold doctoral degrees or to be promoted to higher academic ranks, and they earn less than men. Degree level and career track are themes unique to the PA education profession, and further research is needed to understand their impact. With more women entering PA education, pay equity and promotion need to be addressed.

Impact of online learning on sense of belonging among first year clinical health students during COVID-19: student and academic perspectives

BACKGROUND

The need to belong is a fundamental human desire that provides the basis for relationships and community; it provides a sense of security that enables growth and development. This sense of belonging is pivotal to new University students, indeed, without it, students are at greater risk of failing or withdrawing from their studies. Yet developing a sense of belonging within a new cohort is complex and multi-faceted and further complicated by a sudden shift away from in-person to online learning. Using the situated-learning framework, our study explores first year clinical health students' sense of belonging in the context of the rapid transition to online learning because of the COVID-19 pandemic.

METHODS

We utilised a current mixed-method approach including a survey incorporating previously validated tools, demographic and open-ended qualitative questions. Data was also gathered from three focus groups: two dedicated student groups and one academic focus group. Qualitative data was subjected to thematic analysis whilst descriptive statistics were used to describe the quantitative data.

RESULTS

179 first year students complete the survey and four students, and five academics were involved in the focus groups. All participants were from clinical health science courses at an Australian university. Our qualitative results indicated a global theme of: Navigating belonging during the COVID-19 crisis: a shared responsibility; with four organising themes describing (1) dimensions of belonging, (2) individual experiences and challenges, (3) reconceptualising teaching and learning, and (4) relationships are central to belonging.

CONCLUSION

While the rapid transition to online learning did not greatly impact knowledge acquisition of first-year students in this cohort, the lack of sense of belonging highlights the need for further research into development of this essential aspect of learning in the online domain. Although contextualised in the COVID-19 pandemic, it became clear that the findings will remain relevant beyond the current situation, as a student's need to belong will always be present in the face of challenges or change.

Acceptability of wearable devices for measuring mobility remotely: Observations from the Mobilise-D technical validation study

Background

This study aimed to explore the acceptability of a wearable device for remotely measuring mobility in the Mobilise-D technical validation study (TVS), and to explore the acceptability of using digital tools to monitor health.

Methods

Participants (N = 106) in the TVS wore a waist-worn device (McRoberts Dynaport MM + ) for one week. Following this, acceptability of the device was measured using two questionnaires: The Comfort Rating Scale (CRS) and a previously validated questionnaire. A subset of participants (n = 36) also completed semi-structured interviews to further determine device acceptability and to explore their opinions of the use of digital tools to monitor their health. Questionnaire results were analysed descriptively and interviews using a content analysis.

Results

The device was considered both comfortable (median CRS (IQR; min-max) = 0.0 (0.0; 0-20) on a scale from 0-20 where lower scores signify better comfort) and acceptable (5.0 (0.5; 3.0-5.0) on a scale from 1-5 where higher scores signify better acceptability). Interviews showed it was easy to use, did not interfere with daily activities, and was comfortable. The following themes emerged from participants' as being important to digital technology: altered expectations for themselves, the use of technology, trust, and communication with healthcare professionals.

Conclusions

Digital tools may bridge existing communication gaps between patients and clinicians and participants are open to this. This work indicates that waist-worn devices are supported, but further work with patient advisors should be undertaken to understand some of the key issues highlighted. This will form part of the ongoing work of the Mobilise-D consortium.

A multidisciplinary safety briefing for acutely ill and deteriorating patients: A quality improvement project

BACKGROUND

Safety briefings can help promoting situational awareness, interprofessional communication and improve patient safety.

LOCAL PROBLEM

A clinical survey highlighted that 90% of the participants including the medical team and the critical care outreach team nurses perceived the meeting for escalating acutely ill and deteriorating patients during the out-of-hours period (20.00 to 08.00) to have unconstructive and unwelcoming atmosphere with belittling, hostility and unhelpful criticisms. The participants reported that the communication across teams lacked in structure and clear information given; but staff also self-reported lacking confidence in communicating key issues.

METHOD

A quality improvement project with Plan-Do-Study-Act was adopted to design and implement a dedicated multidisciplinary safety briefing with a structured format.

RESULTS

The multidisciplinary safety briefing was to 90% of clinicians, and it took a median of 10 min to complete. Delayed referrals to the critical care outreach team were reduced by 46%. Positive changes included increased situational awareness and clearer communication across teams. Barriers identified were variable usage and need for face-to-face presence. Considering all the findings and the time constraint during the SARS-CoV-2 pandemic, we changed to a telephonic safety briefing directly to the team leaders.

CONCLUSION

A structured multidisciplinary safety briefing can improve patient safety and support management of deteriorating and acutely ill patients on the wards during the out-of-hours period.

Implementation research protocol on the national community health policy in Guinea: A sequential mixed-methods study using a decision space approach

The overall goal of this study is to explore the rollout of the community health policy in Guinea in the context of decentralization, and the role of decision space (the decision authority, capacities, and accountability of local officials) in explaining gaps between the policy's conceptualization and actual implementation. The implementation research study will employ a sequential explanatory mixed-methods design. The study will be conducted in 27 communes purposefully selected across the country and include communes where the national community health policy is fully, partially, and not yet being implemented. The quantitative component, based on a survey questionnaire and secondary data, will use ordinary least squares (OLS) multiple regression to compare maternal and child health (MCH) coverage indicators according to the level of policy implementation in the commune. An interrupted time series analysis will be conducted to assess changes in routine MCH service delivery indicators associated with implementation of the community health policy, comparing indicators from one year prior to implementation. OLS regression will be conducted to assess the association between decision space and MCH indicators; all analyses will be carried out in Stata. Findings from the quantitative study will be used to inform the key qualitative questions and areas to explore in greater depth, to develop the interview and focus group guides, and to generate an initial codebook. Qualitative data will be double coded in NVivo by two qualitative analysts, and results generated using thematic analysis. Findings from the quantitative and qualitative components will be integrated and triangulated for interpretation and reporting. Findings and recommendations of this study will inform revisions to the National Community Health Policy to improve its rollout and effectiveness.

Integration of pharmacist independent prescribers into general practice: a mixed-methods study of pharmacists' and patients' views

BACKGROUND

Since 2015, the National Health Service (NHS) has funded pharmacists to work in general practice (GP practice) to ease workload pressures. This requires pharmacists to work in new roles and be integrated effectively in GPs. Independent prescribing is a key part of the GP pharmacist role, but little is known about pharmacists' integration into GP practice as well as patients' perceptions and experiences of the care provided by GP pharmacists. This study aims to explore the perceptions of pharmacist independent prescribers (PIPs) about their integration into GP practice and gain insight into patients' perceptions about the care provided to them by pharmacists.

METHODS

A mixed-methods study comprising semi-structured interviews with PIPs (n = 13) followed by questionnaire-based assessment of patients' (n = 77) evaluation of pharmacists' care was conducted between December 2019 and March 2020. Quantitative data were analysed using descriptive statistics. Interviews and open comments of the survey were thematically analysed.

RESULTS

Pharmacist independent prescribers reported undertaking a range of patient-facing and non-clinical roles. Lack of understanding about PIPs' clinical role and working beyond their clinical area of competence were some of the barriers to their integration into GP practice. Most patients were satisfied with the consultations they received from pharmacists and reported confidence in the pharmacist's recommendations about their health conditions. However, a few patients (14%) felt they would still need to consult a general practitioner after their appointment and 11% were not sure if a further consultation was needed.

CONCLUSIONS

Pharmacist independent prescribers provide a range of clinical services for the management of long-term conditions which appear to be recognised by patients. However, there is a need to address the barriers to PIPs' integration into GP practice to optimise their skill-mix and patient-centred care.

Using qualitative interviews to identify patient-reported clinical trial endpoints and analyses that are the most meaningful to patients with advanced breast cancer

BACKGROUND

Designing clinical trials with the emphasis on the patient-centered approach and focusing on clinical outcomes that are meaningful to patients is viewed as a priority by drug developers, regulatory agencies, payers, clinicians, and patients. This study aimed to capture information on clinical trial endpoints that would be most important and relevant for patients with advanced breast cancer, based on patient-reported outcomes.

METHODS

Patients with either advanced triple-negative breast cancer [TNBC] and a maximum of two lines of systemic therapy or hormone receptor-positive/human epidermal growth factor receptor 2-negative [HR+/HER2-] breast cancer and a maximum of three lines of systemic therapy, participated in semi-structured concept elicitation interviews. Concept saturation was assessed. A sign, symptom, or impact was defined as "salient" if mentioned by ≥ 60% of participants, with an average bother rating of ≥ 5 (0-10 Scale). Participants were also asked about treatment priorities and to evaluate hypothetical scenarios showing different health-related functioning and quality-of-life treatment outcomes, using graphical representations.

RESULTS

Thirty-two participants (97% women; aged 29+ years) with TNBC (n = 17) or HR+/HER2- breast cancer (n = 15) provided generally similar reports on symptom experience, with fatigue and pain being most salient, though importance of certain treatment-related symptoms varied between the two groups. Patients reported consistent perspectives on the importance of treatment outcomes: when considering a new treatment, they prioritized efficacy of the therapy, acceptable tolerability, stability, predictability of symptoms over time, and the duration of preserved health-related quality of life and physical functioning. The meaningful difference in preserved physical functioning was 2-3 months for 46% of participants with TNBC, whereas for most participants with HR+/HER2- breast cancer it started from 6-7 months. Both groups of participants found it easier to accept some toxicity at the beginning of therapy if it was followed by improvement, as opposed to improvement followed by deterioration.

CONCLUSION

The results may help to inform the design of patient-centered clinical trials, to interpret health-related quality of life and/or patient-reported outcomes, and to optimize care for patients with advanced breast cancer.

Evaluation of the Community Health Worker Model for COVID-19 Response and Recovery

Community health workers (CHWs), or promotores de salud, have long played a role in health promotion, but the COVID-19 pandemic has brought renewed attention to the functions, sustainability, and financing of CHW models. ¡Andale! ¿Que Esperas? was a 12-month (June 2021-May 2022) campaign that expanded the CHW workforce to increase COVID-19 vaccination rates in structurally vulnerable, Latinx communities across California. This mixed-methods evaluation aims to elucidate (1) the role of CHWs in COVID-19 response, recovery, and rebuilding and (2) the importance, needs, and perils of CHW models in the COVID-19 era and beyond. CHWs facilitated 159,074 vaccinations and vaccine appointments by countering mis/disinformation, addressing mental health and social needs, building digital competencies, and meeting people where they are, all of which expanded access and instilled confidence in the COVID-19 vaccine. CHWs' success in engaging the community lies in their shared lived experience as well as their accessibility and recognition in the community, enabling their role in both immediate response and long-term recovery. Funding instability imperils the advances made by CHWs, and efforts are needed to institutionalize the CHW workforce with sustainable funding models. While Medicaid reimbursement models exist in some states, these models are often limited to healthcare services, overlooking a critical function of the CHW model: building community resilience and mobilizing the community for social change.

Implementation and Preliminary Effectiveness of a Multidisciplinary Telemedicine Pilot Initiative for Patients with Chronic Non-Cancer Pain in Rural and Underserved Areas at a Major Academic Medical Center

Background

Arkansas lacks adequate access to high-quality pain care, as evidenced, in part, by it having the second highest opioid prescribing rate in the United States. To improve access to high-quality treatment of chronic pain, we developed the Arkansas Improving Multidisciplinary Pain Care and Treatment (AR-IMPACT) Telemedicine Clinic, a multidisciplinary and interprofessional team of specialists who provide evidence-based pain management for patients with chronic pain.

Methods

We conducted a single-arm pilot trial of the AR-IMPACT Telemedicine Clinic with rural, university-affiliated primary care clinics. We assessed the AR-IMPACT Telemedicine Clinic using an implementation framework and preliminary effectiveness measures. Specifically, we assessed 5 of the 8 implementation outcomes of the framework (ie, penetration, adoption, acceptability, appropriateness, and feasibility) using a mixed methods approach. To evaluate implementation outcomes, we used surveys, interviews, and administrative data. We used electronic health record data to measure preliminary effectiveness (ie, changes in average morphine milligram equivalents per day and pain and depression scores).

Results

The AR-IMPACT team saw 23 patients that were referred by 13 primary care physicians from three rural, university-affiliated primary care clinics over one year. Of the 19 patients willing to participate in the pilot study, 12 identified as women, 31.6% identified as Black, and over 50% had less than a bachelor's level education. Patients rated the clinic positively with high overall satisfaction. Referring physicians indicated high levels of appropriateness, acceptability, and feasibility of the program. AR-IMPACT team members identified several barriers and facilitators to the feasibility of implementing the program. No changes in preliminary effectiveness measures were statistically significant.

Conclusion

Overall, the AR-IMPACT Telemedicine Clinic obtained moderate penetration and adoption, was highly acceptable to patients, was highly acceptable and appropriate to providers, and was moderately feasible to providers and AR-IMPACT team members.

CSR-brand relationship, brand positioning, and investment risks driven towards climate change mitigation and next perspectives emerging from: "Litigation, projections, pathway, and models"

This study delineates the relationship between CSR and brands, unveiling pragmatic steps towards achieving the sustainable business environment, while unveiling its potential towards climate changes mitigation cognizant of investment risks, leading to an action plan-framework for proffering practical solutions coupled with establishing future paths and projection towards addressing climatic changes consequences, risen incidences in litigation trends and environmental issues. Trends manifesting in risen litigation incidences linked to industrial and economic activities that adversely impact the climate, environment and society makes it imperative to look extensively beyond prediction models while establishing and building on brand relationship with CSR, while strategically establishing a practically realistic business model for translating this relationship to value-creation and applied in abating climate change, addressing all environmental concerns, redressing litigation incidences, among other issues resulting from impacts of business and socio-economic pursuits of humans. The twenty-first century realities towards a green planet demands doing business strategically, optimize resources by imbibing investment risks as a trend and organizational culture-strategic fit, adopting brand as a potential tool for addressing climate change and environmentally related activities and adversaries from business activities and negligent practices from such, while achieving climate change mitigation as outlined and extensively inundated.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43546-022-00374-4.

Identifying Future Study Designs for Mental Health and Social Wellbeing Associated with Diets of a Cohort Living in Eco-Regions: Findings from the INSUM Expert Workshop

Diets influence our mental health and social wellbeing (MHSW) in multiple ways. A rising community concept, Eco-Regions, has gained interest. The research project "Indicators for assessment of health effects of consumption of sustainable, organic school meals in Ecoregions" (INSUM) aims to develop future-oriented research approaches to measure the potential health effects of more sustainable and healthy diets. This first part of the project focuses on MHSW with the goal to identify suitable study designs and indicators. The methodology is based on a 2-day workshop with an interdisciplinary group of experts. This paper describes commonly applied research methods on the nexus between diet and MHSW as presented by the experts and summarises key points from the discussions. The results show that the dominating tool to investigate MSHW is questionnaires. Questionnaires vary largely depending on the research design, such as participants or distribution channels. Cohort studies addressing families and including in-depth interventional and/or experimental studies may be suitable for an Eco-Region investigation. Those MHSW studies can be conducted and combined with measurements of somatic health effects. We conclude that indicators should be seen as complementary rather than independent. Explorative research designs are required to investigate complex Eco-Regions.

Treatment of anastomotic leak after esophagectomy: insights of an international case vignette survey and expert discussions

Anastomotic leak (AL) is a severe complication after esophagectomy. Clinical presentation of AL is diverse and there is large practice variation regarding treatment of AL. This study aimed to explore different AL treatment strategies and their underlying rationale. This mixed-methods study consisted of an international survey among upper gastro-intestinal (GI) surgeons and focus groups with expert upper GI surgeons. The survey included 10 case vignettes and data sources were integrated after separate analysis. The survey was completed by 188 respondents (completion rate 69%) and 6 focus groups were conducted with 20 international experts. Prevention of mortality was the most important goal of primary treatment. Goals of secondary treatment were to promote tissue healing, return to oral feeding and safe hospital discharge. There was substantial variation in the preferred treatment principles (e.g. drainage or defect closure) and modalities (e.g. stent or endoVAC) within different presentations of AL. Patients with local symptoms were treated by supportive means only or by non-surgical drainage and/or defect closure. Drainage was routinely performed in patients with intrathoracic collections and often combined with defect closure. Patients with conduit necrosis were predominantly treated by resection and reconstruction of the anastomosis or by esophageal diversion. This mixed-methods study shows that overall treatment strategies for AL are determined by vitality of the conduit and presence of intrathoracic collections. There is large variation in preferred treatment principles and modalities. Future research may investigate optimal treatment for specific AL presentations and aim to develop consensus-based treatment guidelines for AL after esophagectomy.

Perceived mental health and emotional trajectories of long-term family caregivers of persons with mental conditions: A mixed-methods study

AIMS AND OBJECTIVES

To explore the emotional experience and the perceived mental health of experienced family caregivers of people with mental disorders.

BACKGROUND

Family caregiving for individuals with mental disorders differs from other health conditions, as it implies a burden, deterioration in physical and mental health, stigma and a perceived lack of support from mental health services.

METHODS

A mixed-method study was undertaken with family caregivers of people diagnosed with mental disorders.

RESULTS

A total of 13 experienced family caregivers were included in the study. The qualitative data were classified into two major themes: emotions and perceived mental health. Emotions included five categories: irritability, painful emotions, pressure, emotions orientated towards coping, and positive emotions. The perceived mental health status embraced five categories: anxiety, burden and exhaustion, needing psychological or psychiatric treatment, insomnia and suicidal thoughts. An emotional path could be constructed from their discourses, starting with lack of control or irritation that evolved towards resignation, peace or satisfaction. The quantitative analysis partially replicated the qualitatively reported anxiety, depressive symptoms and insomnia.

CONCLUSION

Past and present emotions related to caregiving described by experienced family caregivers were identified. Their emotional trajectories converged in that negative emotions gave way to emotions towards coping, which in turn were followed by positive emotions. The participants' descriptions about their mental status were partially reflected through objective mental health measurements.

RELEVANCE TO CLINICAL PRACTICE

More support from mental health services could help caregivers to progress in their emotional trajectory towards coping, and improve their caregiving knowledge and skills. Mental health nurses have a role in patients and caregivers education and in the promotion of caregivers' psychological wellbeing.

Challenges associated with the integration of immuno-oncology agents in clinical practice

BACKGROUND

The availability of new immuno-oncology therapeutics markedly impacts oncology clinicians' treatment decision-making. To effectively support healthcare professionals (HCPs) in their practice, it is important to better understand the challenges and barriers that can accompany the introduction of these agents. This study aimed to establish the types and causes of clinical challenges posed by the introduction of new immuno-oncology agents.

METHODS

The mixed-methods design included qualitative in-depth interviews and group discussions with HCPs, in which participants discussed clinical challenges and potential underlying reasons for these challenges. Qualitative findings informed a quantitative survey. This survey investigated the extent and distribution of challenges using HCPs' self-rating of knowledge, skill, confidence, and exposure to system-level effects. These two phases were conducted sequentially with distinctly stratified samples of oncologists, nurse practitioners (NPs), physician assistants (PAs), pathologists, clinical pharmacists, interventional radiologists, rheumatologists, pulmonologists, and emergency department physicians. Participants were from the United States and had various levels of clinical experience and represented both academic and community-based settings.

RESULTS

The final sample included 107 HCPs in the qualitative phase and 554 in the quantitative phase. Analyses revealed clinical challenges related to the use of pharmacodiagnostics. For example, 47% of pathologists and 42% of oncologists reported skill gaps in identifying the appropriate marker and 46% of oncologists, 61% of PAs, 66% of NPs, 74% of pulmonologists and 81% of clinical pharmacists reported skill gaps in selecting treatment based on test results. Challenges also emerged regarding the integration of immuno-oncology agents, as oncologists, rheumatologists, pulmonologists, clinical pharmacists, PAs, and NPs reported knowledge gaps (74-81%) of the safety profiles of recently approved agents. In addition, 90% of clinical pharmacists reported skill gaps weighing the risks and benefits of treating patients with immuno-oncology agents while affected by lupus. Finally, patient communication challenges were identified: HCPs reported difficulties discussing essential aspects of immunotherapy to patients as well as how they might compare to other types of therapies.

CONCLUSION

The challenges highlighted in this study reveal substantial educational gaps related to the integration of immuno-oncology agents into practice for various groups of HCPs. These findings provide a strong base of evidence for future educational initiatives.

Disengagement from early psychosis intervention services: an observational study informed by a survey of patient and family perspectives

Approximately one-third of patients with early psychosis disengage from services before the end of treatment. We sought to understand patient and family perspectives on early psychosis intervention (EPI) service engagement and use these findings to elucidate factors associated with early disengagement, defined as dropout from EPI in the first 9 months. Patients aged 16-29 referred to a large EPI program between July 2018-February 2020 and their family members were invited to complete a survey exploring facilitators and barriers to service engagement. A prospective chart review was conducted for 225 patients consecutively enrolled in the same EPI program, receiving the NAVIGATE model of coordinated specialty care, between July 2018-May 2019. We conducted a survival analysis, generating Kaplan-Meier curves depicting time to disengagement and Cox proportional hazards models to determine rate of disengagement controlling for demographic, clinical, and program factors. The survey was completed by 167 patients and 79 family members. The top endorsed engagement facilitator was related to the therapeutic relationship in both patients (36.5%) and families (43.0%). The top endorsed barrier to engagement was medication side effects in both patients (28.7%) and families (39.2%). In Cox proportional hazards models, medication nonadherence (HR = 2.37, 95% CI = 1.17-4.80) and use of individual psychotherapy (HR = .460, 95% CI = 0.220-0.962) were associated with early disengagement, but some of the health equity factors expected to affect engagement were not. Findings suggest that delivery of standardized treatment may buffer the effects of health disparities on service disengagement in early psychosis.

"We need to protect each other": COVID-19 vaccination intentions and concerns among Racialized minority and Indigenous Peoples in Canada

People may choose to receive vaccines in response to pressures that outweigh any concerns that they have. We explored Racialized minority and Indigenous Peoples' motivations for, perceptions of choice in, and concerns about, COVID-19 vaccination. We used a sequential explanatory mixed methods approach, including a national survey administered around the time vaccines were first authorized (Dec 2020) followed by qualitative interviews when vaccines were becoming more readily available to adults (May-June 2021). We analyzed survey data using descriptive statistics and interviews using critical feminist methodologies. Survey respondents self-identified as a Racialized minority (n = 1488) or Indigenous (n = 342), of which 71.4% and 64.6%, respectively, intended to receive a COVID-19 vaccine. Quantitative results indicated perceptions of COVID-19 disease were associated with vaccination intention. For instance, intention was associated with agreement that COVID-19 disease is severe, risk of becoming sick is great, COVID-19 vaccination is necessary, and vaccines available in Canada will be safe (p < 0.001). COVID-19 vaccines were in short supply in Canada when we subsequently completed qualitative interviews with a subset of Racialized minority (n = 17) and Indigenous (n = 10) survey respondents. We coded interview transcripts around three emergent themes relating to governmentality and cultural approaches to intersectional risk theories: feelings of collective responsibility, choice as privilege, and remaining uncertainties about COVID-19 vaccines. For example, some mentioned the responsibility and privilege to receive a vaccine earlier than those living outside of Canada. Some felt constraints on their freedom to choose to receive or refuse a vaccine from intersecting oppressions or their health status. Although all participants intended to get vaccinated, many mentioned uncertainties about the safety and effectiveness of COVID-19 vaccination. Survey respondents and interview participants demonstrated nuanced associations of vaccine acceptance and hesitancy shaped by perspectives of vaccine-related risks, symbolic associations of vaccines with hope, and intersecting social privileges and inequities (including racialization).

Using mixed-methods in evidence-based nursing: a scoping review guided by a socio-ecological perspective

Background

Increased pressure for evidence-based practice in nursing necessitates that researchers use effective approaches. Mixed-methods research (MMR) has potential to improve the knowledge and implementation of evidence-based nursing (EBN) by generating outcome-based and contextually-focused evidence.

Aims

To identify methodological trends in how MMR is used in EBN research.

Methods

Searches were completed in PubMed, CINAHL, and Google Scholar using the terms "nursing", "mixed-methods", and "evidence-based". Seventy-two articles using MMR to address EBN and published 2000-2021 were reviewed across content themes and methodological domains of the Socio-Ecological Framework for MMR.

Results

Mixed-methods research has been used to study how EBN strategies are perceived, developed and assessed, and implemented or evaluated. A few studies provided an MMR definition reflecting the methods perspective, and the dominant MMR rationale was gaining a comprehensive understanding of the issue. The leading design was concurrent, and half of studies intersected MMR with evaluation, action/participatory, and/or case-study approaches. Research quality was primarily assessed using criteria specific to quantitative and qualitative approaches.

Conclusions

Mixed-methods research has great potential to enhance EBN research by generating more clinically useful findings and helping nurses understand how to identify and implement the best available research evidence in practice.

Grief reaction, depression, anxiety, and coping of relatives after palliative patients' death in Thailand

INTRODUCTION

Grief is a normal psychological response in relatives after the loss of their loved ones, which has shown to be associated with psychological reactions like depression, anxiety, and significant stress that many relatives have to cope with. In Thailand, there are limited research studies on grief, especially in palliative settings. This study aims to examine grief reaction, depression, anxiety, and coping of relatives after palliative patients' death.

MATERIALS AND METHODS

A multi-method design was applied. The authors completed the demographic data questionnaire, and the participants finished other measures which included the Hospital Anxiety and Depression Scale (HADS), the Inventory of Complicated Grief (ICG), and the Brief-Coping Orientation to Problems Experienced (Brief-COPE). The qualitative data from the focus group interview was analyzed with thematic analysis.

RESULTS

From the quantitative study, the mean scores of HADS for anxiety and depression subscales were 5.05 and 6.34, respectively, which indicated no anxiety and depressive disorders. The mean score of ICG was 19.51 with highest score on acceptance coping subscale. In contrast, the lowest score was on dealing with the substance subscale. There were significant correlations between anxiety subscale from HADS and ICG (r = 0.73), depression subscale from HADS and ICG(r = 0.85), and anxiety and depression subscale from the HADS (r = 0.79). From the qualitative study, the factors associated with grief reaction could be thoroughly explained according to the perceived character of deceased, perceived character of relatives, relationship characteristics, disease, medical care, and support systems.

CONCLUSION

The correlations among grief reaction, depression, and anxiety of relatives after palliative patients' death were high. The grief reaction was associated with many factors, including communication from medical personnel. This finding emphasized the importance of assessing the reactions after loss and associated factors in the relatives after palliative patients' death. Also, evaluating the ways that the relatives use to cope with their loss, expressing empathy, and supporting the relatives to cope with loss in an adaptive way were recommended.

A framework for understanding how midwives perceive and provide care management for pregnancies complicated by gestational diabetes or hypertensive disorders of pregnancy

BACKGROUND

Both gestational diabetes mellitus (GDM) and hypertensive disorders of pregnancy (HDP) are common, and each are associated with adverse maternal and perinatal outcomes. Midwives may be the first point of care when these conditions arise. This study evaluated the experiences of midwives when providing care to women and people with pregnancies complicated by GDM or HDP.

METHODS

A mixed methods study was completed in Ontario, Canada, using a sequential, explanatory approach. A total of 144 online surveys were completed by midwives, followed by 20 semi-structured interviews that were audio recorded and transcribed verbatim. Survey data were analysed using descriptive statistics. Thematic analysis was used to generate codes from the interview data, which were mapped to the Theoretical Domains Framework (TDF), to elucidate factors that might influence management.

RESULTS

Most of the midwives' clinical behaviours relating to GDM or HDP were in keeping with guidelines and regulatory standards set by existing provincial standards. Six theoretical domains from the TDF appeared to influence midwives'care pathway: "Internal influences" included knowledge, skills and beliefs about capabilities; while "external influences" included social/professional role and identity, environmental context, and social influences. Interprofessional collaboration emerged as a significant factor on both the internal and external levels of influence.

CONCLUSIONS

We identified barriers and facilitators that may improve the experiences of midwives and clients when GDM or HDP newly arises in a pregnancy, necessitating further consultation or management by another health care provider.

Addressing the need for an appropriate skilled delivery care workforce in Burundi to support Maternal and Newborn Health Service Delivery Redesign (MNH-Redesign): a sequential study protocol

Background Despite Burundi having formed a network of 112 health facilities that provide emergency obstetric and neonatal care (EmONC), the country continues to struggle with high rates of maternal and newborn deaths. There is a dearth of empirical evidence on the capacity and performance of EmONC health facilities and on the real needs to inform proper planning and policy. Our study aims to generate evidence on the capacity and performance of EmONC health facilities in Burundi and examine how the country might develop an appropriate skilled delivery care workforce to improve maternal and newborn survival. Methods We will use a sequential design where each study phase serially inputs into the subsequent phase. Three main study phases will be carried out: i) an initial policy document review to explore global norms and local policy intentions for EmONC staffing and ii) a cross-sectional survey of all EmONC health facilities to determine what percent of facilities are functional including geographic and population coverage gaps, identify staffing gaps assessed against norms, and identify other needs for health facility strengthening. Finally, we will conduct surveys in selected schools and ministries to examine training and staffing costs to inform staffing options that might best promote service delivery with adequate budget impacts to increase efficiency. Throughout the study, we will engage stakeholders to provide input into what are reasonable staffing norms as well as feasible staffing alternatives within Burundi's budget capacity. Analytical models will be used to develop staffing proposals over a realistic policy timeline. Conclusion Evidence-based health planning improves cost-effectiveness and reduces wastage within scarce and resource-constrained contexts. This study will be the first large-scale research in Burundi that builds on stakeholder support to generate evidence on the capacity of designated EmONC health facilities including human resources diagnosis and develop staffing skill-mix tradeoffs for policy discussion.

A stakeholder engagement strategy for an ongoing research program in rural dementia care: Stakeholder and researcher perspectives

Participatory research approaches have developed in response to the growing emphasis on translation of research evidence into practice. However, there are few published examples of stakeholder engagement strategies, and little guidance specific to larger ongoing research programs or those with a rural focus. This paper describes the evolution, structure, and processes of an annual Rural Dementia Summit launched in 2008 as an engagement strategy for the Rural Dementia Action Research (RaDAR) program and ongoing for more than 10 years; and reports findings from a parallel mixed-methods study that includes stakeholder and researcher perspectives on the Summit’s value and impact. Twelve years of stakeholder evaluations were analyzed. Rating scale data were summarized with descriptive statistics; open-ended questions were analyzed using an inductive thematic analysis. A thematic analysis was also used to analyze interviews with RaDAR researchers. Rating scale data showed high stakeholder satisfaction with all aspects of the Summit. Five themes were identified in the qualitative data: hearing diverse perspectives, building connections, collaborating for change, developing research and practice capacity, and leaving recharged. Five themes were identified in the researcher data: impact on development as a researcher, understanding stakeholder needs, informing research design, deepening commitment to rural dementia research, and building a culture of engagement. These findings reflect the key principles and impacts of stakeholder engagement reported in the literature. Additional findings include the value stakeholders place on connecting with stakeholders from diverse backgrounds, how the Summit was revitalizing, and how it developed stakeholder capacity to support change in their communities. Findings indicate that the Summit has developed into a community of practice where people with a common interest come together to learn and collaborate to improve rural dementia care. The Summit’s success and sustainability are linked to RaDAR’s responsiveness to stakeholder needs, the trust that has been established, and the value that stakeholders and researchers find in their participation.

Post-acute COVID and long-COVID among adults and older adults in the State of Paraná, Brazil: protocol for an ambispective cohort study

INTRODUCTION

Since 2020, the world has been going through a viral pandemic with a high morbidity and mortality rate along with the potential to evolve from an acute infection to post-acute and long-COVID, which is still in the process of elucidation. Diagnostic and prognostic research is essential to understand the complexity of factors and contexts involving the illness's process. This protocol introduces a study strategy to analyse predictors, sequelae, and repercussions of COVID-19 in adults and older adults with different disease severities in the State of Paraná, Brazil.

METHODS AND ANALYSIS

A mixed-methods sequential explanatory design. The quantitative data will be conducted by an ambispective cohort study, which will explore the manifestations of COVID-19 for 18 months, with nearly 3000 participants with confirmed diagnoses of COVID-19 (reverse transcription-PCR test) between March and December of 2020, retrieved from national disease reporting databases, over 18 years old, living in a Brazilian State (Paraná) and who survived the viral infection after being discharged from a health service. Data collection will be conducted through telephone interviews, at two different occasions: the first will be a recall 12 months after the acute phase as a retrospective follow-up, and the second will be another prospective interview, with data of the following 6 months. For the qualitative step, Grounded Theory will be used; participants will be selected from the cohort population. The first sample group will be composed of people who were discharged from the intensive care unit, and other sample groups will be composed according to theoretical saturation. The qualitative data will follow the temporal design and classification of the disease provided for in the cohort.

ETHICS AND DISSEMINATION

Ethics approval was granted by the State University of Maringá, under opinion number: 4 165 272 and CAAE: 34787020.0.0000.0104 on 21 July 2020, and Hospital do Trabalhador (Worker's Hospital), which is accountable for the Health Department of the State of Paraná, under opinion number: 4 214 589 and CAAE: 34787020.0.3001.5225 on 15 August 2020. The participants will verbally consent to the research, their consent will be recorded, and the informed consent form will be sent by mail or email. Outcomes will be widely disseminated through peer-reviewed manuscripts, conference presentations, media and reports to related authorities.

Loneliness, social isolation, and social support in older adults with active cancer during the COVID-19 pandemic

Introduction

The COVID-19 pandemic has had a considerable impact on mental health. The social distancing and stay-at-home orders have likely also impacted loneliness, social isolation, and social support. Older adults, particularly those with comorbidities such as cancer, have a greater potential to be impacted. Here we assessed loneliness, social isolation, and social support in older adults undergoing active cancer treatment during the pandemic.

Materials and methods

A mixed methods study in which quantitative data and qualitative response items were collected in parallel was conducted in 100 older adults with cancer. Participants completed a survey by telephone with a series of validated questionnaires to assess the domains of loneliness, social isolation, and social support as well as several open-ended questions. Baseline demographics and geriatric assessments were summarized using descriptive statistics. Bivariate associations between social isolation and loneliness and social support and loneliness were described using Spearman correlation coefficients. Conventional content analysis was performed on the open-ended questions.

Results

In a population of older adults with cancer, 3% were noted to be severely lonely, although 27% percent screened positive as having at least one indicator of loneliness by the University of California, Los Angeles (UCLA) Three Item Loneliness Scale. There was a significant positive correlation between loneliness and social isolation (r = +0.52, p < 0.05) as well as significant negative correlation between loneliness and social support (r = −0.49, p < 0.05). There was also a significant negative correlation between loneliness and emotional support (r = −0.43, p < 0.05). There was no significant association between loneliness and markers of geriatric impairments, including comorbidities, G8 score or cognition.

Discussion

Reassuringly, in this cohort we found relatively low rates of loneliness and social isolation and high rates of social support. Consistent with prior studies, loneliness, social isolation, and social support were found to be interrelated domains; however, they were not significantly associated with markers of geriatric impairments. Future studies are needed to study if cancer diagnosis and treatment may mediate changes in loneliness, social isolation, and social support in the context of the pandemic as well as beyond.

Ultra-Orthodox Nursing Students’ Cultural Challenges Inside and Outside Their Community during the COVID-19 Pandemic

In line with findings that nurses from minority groups have an important role in making health services accessible to their community, our study aimed to identify the challenges ultra-Orthodox Jewish nurses faced during COVID-19 in their encounters with patients and health staff from other communities, as well as their own community. The ultra-Orthodox community is a highly religious group that maintains isolation from general society, a phenomenon that affected its member experiences during COVID-19. Our research followed sequential explanatory mixed methods. The quantitative phase included a questionnaire completed by 235 female students (111 ultra-Orthodox and 124 non-ultra-Orthodox), followed by a qualitative phase, which included six focus-groups (n = 15). The quantitative analysis showed that the ultra-Orthodox students felt a higher sense of responsibility toward their community. They used their authority and knowledge to guide their community during the pandemic. The qualitative analysis identified two themes expressed as challenges ultra-Orthodox nursing students encountered within their community and with other sections of Israeli society. Our research shows the important role that transcultural nurses play in mediating updated health information otherwise inaccessible to their community, especially in times of crises. It is important to address dilemmas this group faces inside and outside their respective communities.

Addressing the need for an appropriate skilled delivery care workforce in Burundi to support Maternal and Newborn Health Service Delivery Redesign (MNH-Redesign): a sequential study protocol

Background Despite Burundi having formed a network of 112 health facilities that provide emergency obstetric and neonatal care (EmONC), the country continues to struggle with high rates of maternal and newborn deaths. There is a dearth of empirical evidence on the capacity and performance of EmONC health facilities and on the real needs to inform proper planning and policy. Our study aims to generate evidence on the capacity and performance of EmONC health facilities in Burundi and examine how the country might develop an appropriate skilled delivery care workforce to improve maternal and newborn survival. Methods We will use a sequential design where each study phase serially inputs into the subsequent phase. Three main study phases will be carried out: i) an initial policy document review to explore global norms and local policy intentions for EmONC staffing and ii) a cross-sectional survey of all EmONC health facilities to determine what percent of facilities are functional including geographic and population coverage gaps, identify staffing gaps assessed against norms, and identify other needs for health facility strengthening. Finally, we will conduct surveys in schools and different ministries to examine training and staffing costs to inform staffing options that might best promote service delivery with adequate budget impacts to increase efficiency. Throughout the study, we will engage stakeholders to provide input into what is reasonable staffing norms as well as feasible staffing alternatives within Burundi's budget capacity. Analytical models will be used to develop staffing proposals over a realistic policy timeline. Conclusion Evidence-based health planning improves cost-effectiveness and reduces wastage within scarce and resource-constrained contexts. This study will be the first large-scale research in Burundi that builds on stakeholder support to generate evidence on the capacity of designated EmONC health facilities including human resources diagnosis and develop staffing skill-mix tradeoffs for policy discussion.

Impact of COVID-19 on corporate social responsibility in India – a mixed methods approach

Purpose

Prior research studies have discussed the role of corporate social responsibility (CSR) during crisis situations in increasing the resilience and sustainability of the companies. There are two basic models of crisis management – reactive and proactive. When a crisis occurs, suddenly firms tend to act reactively and progressively take proactive steps to manage the crisis. CSR can also be reactive and proactive during crisis situations. Against this backdrop, this paper aims to explore whether CSR during the COVID-19 pandemic moved from a reactive to a proactive stance, with specific focus on CSR legislation, corporate CSR response and corporate thinking about CSR.

Design/methodology/approach

This paper adopts a mixed methods approach, using both qualitative and quantitative research designs. This study draws upon both primary and secondary data.

Findings

The results highlighted the change in the CSR approach from being reactive to being proactive as the pandemic progressed. This was observed through the increase in frequency of CSR legislation, and the shift in the intent of CSR legislation from “prompting to donate” to “prompting to volunteer.” Similarly, the shift in reactive to proactive CSR corporate response was observed through the increased spending on CSR and improved COVID-related CSR reporting.

Practical implications

This study recommends companies to manage crises by becoming more proactive. CSR activities need to be closely aligned with national developmental objectives, and collaborate with various stakeholders to achieve the intended outcomes of the activities.

Originality/value

To the best of the authors’ knowledge, this research paper is one of the few to study the impact of COVID-19 pandemic on CSR in India at a time when India went through three waves of the pandemic. This study corroborates with other studies in terms of managing crisis.

Analysis of Undergraduates’ Environmentally Friendly Behavior: Case Study of Tzu Chi University Environmental Education Program

The Tzu Chi University Environmental Education Program, based on a theory of change, consisted of four weeks of lessons involving environmental and sustainability topics, followed by hands-on sorting of recyclables and four weeks of weekly documenting of environmentally friendly behavior. The Program was analyzed using written thoughts from the Experimental Group, as well as 78 and 116 valid survey responses of the Control and Experimental Groups, respectively. The survey consisted of questions regarding demographics and five constructs: environmental awareness, attitudes, norms, efficacy and behavior. No significant average differences were found between the pre-tests of the Control and Experimental Groups, or between the pre- and post-test of the Control Group. The post-test of the Experimental Group displayed a significantly higher average value when compared to both the pre-test of the Experimental Group and the post-test of the Control Group, as the means of the self-reported environmental awareness, attitudes, norms, efficacy and behavior significantly improved statistically after participating in the Program. Analysis revealed that lessons from the Program increased undergraduates’ environmental awareness and attitudes; “hands-on recyclables sorting” and “weekly documentation of environmentally friendly behavior” strengthened undergraduates’ environmental norms and efficacy, while their combination resulted in a significant improvement toward environmentally friendly behavior.

Monitoring and Managing Lifestyle Behaviors Using Wearable Activity Trackers: Mixed Methods Study of Views From the Huntington Disease Community

Background

There are early indications that lifestyle behaviors, specifically physical activity and sleep, may be associated with the onset and progression of Huntington disease (HD). Wearable activity trackers offer an exciting opportunity to collect long-term activity data to further investigate the role of lifestyle, physical activity, and sleep in disease modification. Given how wearable devices rely on user acceptance and long-term adoption, it is important to understand users’ perspectives on how acceptable any device might be and how users might engage over the longer term.

Objective

This study aimed to explore the perceptions, motivators, and potential barriers relating to the adoption of wearable activity trackers by people with HD for monitoring and managing their lifestyle and sleep. This information intended to guide the selection of wearable activity trackers for use in a longitudinal observational clinical study.

Methods

We conducted a mixed methods study; this allowed us to draw on the potential strengths of both quantitative and qualitative methods. Opportunistic participant recruitment occurred at 4 Huntington’s Disease Association meetings, including 1 international meeting and 3 United Kingdom–based regional meetings. Individuals with HD, their family members, and carers were invited to complete a user acceptance questionnaire and participate in a focus group discussion. The questionnaire consisted of 35 items across 8 domains using a 0 to 4 Likert scale, along with some additional demographic questions. Average questionnaire responses were recorded as positive (score>2.5), negative (score<1.5), or neutral (score between 1.5 and 2.5) opinions for each domain. Differences owing to demographics were explored using the Kruskal-Wallis and Wilcoxon rank sum tests. Focus group discussions (conducted in English) were driven by a topic guide, a vignette scenario, and an item ranking exercise. The discussions were audio recorded and then analyzed using thematic analysis.

Results

A total of 105 completed questionnaires were analyzed (47 people with HD and 58 family members or carers). All sections of the questionnaire produced median scores >2.5, indicating a tendency toward positive opinions on wearable activity trackers, such as the devices being advantageous, easy and enjoyable to use, and compatible with lifestyle and users being able to understand the information from trackers and willing to wear them. People with HD reported a more positive attitude toward wearable activity trackers than their family members or caregivers (P=.02). A total of 15 participants participated in 3 focus groups. Device compatibility and accuracy, data security, impact on relationships, and the ability to monitor and self-manage lifestyle behaviors have emerged as important considerations in device use and user preferences.

Conclusions

Although wearable activity trackers were broadly recognized as acceptable for both monitoring and management, various aspects of device design and functionality must be considered to promote acceptance in this clinical cohort.

The perceptions and attitudes of qualified dental therapists towards a diagnostic role in the provision of paediatric dental care

Objectives This study explored the perceptions and attitudes of qualified UK dental therapists (DTs) to act in a diagnostic role in the dental care of paediatric patients.Methods A mixed methods study. An electronic questionnaire was sent out to the members of associations and closed social networking groups for qualified DTs across the UK. The questionnaire explored the training, clinical experience and working practices of the participants and measured their agreements with applicable statements using Likert scale scores. Semi-structured interviews were also undertaken to explore how UK DTs perceived a diagnostic role for them and what barriers and facilitators they experienced.Results A total of 155 questionnaire responses were returned and 11 interviews conducted. Participants were mostly women (94.8%) with a broad range of working experience, with a mean experience of 9.5 years (± 8.8 standard deviation [SD]) (range: 1-42 years). From the questionnaires, when asked to score agreement on a Likert scale from 0-5, DTs agreed that in a diagnostic role, they could increase access to dentistry for patients and a high proportion were in agreement that they had the knowledge to carry out examination (mean = 4.43 ± 0.87 SD), diagnosis (mean = 4.37 ± 0.90 SD) and care planning for paediatric patients (mean = 2.74 ± 1.32 SD). The interviews yielded three qualitative supra themes: 'working in the UK as a DT today'; 'the perceptions of dental therapists on acting in a diagnostic role in paediatric dental care'; and 'barriers and facilitators to acting in a diagnostic role' and within these, eight major themes were identified.Conclusion Within the limitations of a small sample who were representative of the workforce demographic and educational structures, we found that DTs felt that if they were to act in a diagnostic role, it would improve access to dental services benefitting patients, dentists and the DT profession. DTs identified and explored barriers and facilitators to a diagnostic role. Change is required to overcome these barriers in order to support DTs to act in a front-line diagnostic role.

Leadership academy for excellence in disability services: evaluation of outcomes for state employees

As the United States' first disability-specific leadership academy in state government, the Leadership Academy for Excellence in Disability Services is a year-long competency-based training experience designed for employees who manage programs that impact the lives of Tennesseans with intellectual and developmental disabilities and their families. The Tennessee Department of Human Resources, in collaboration with the Tennessee Council on Developmental Disabilities, began implementing this program in 2017. The lasting impact of such a training experience on the practices of state employees once they complete the program is not known; this was the aim of the study. A follow-up survey examining graduate perceptions and outcomes was sent to 71 graduates; 48 completed the measure. The results reveal an increase in knowledge of disability service systems and a perceived ability to lead and advocate for others. Leadership competencies deemed most important to graduates' current efforts in state government included developing direct reports, managing diversity, organizational agility, and innovation management. Graduates' written comments cited the variety of subject matter experts, networking opportunities, and small group projects as fundamental in breaking down barriers to cross-agency collaboration in their disability work. The impact of this experience continues to be seen years after completing the leadership academy.

Process Evaluation of an Implementation Trial: Design, Rationale, and Early Lessons Learnt From an International Cluster Clinical Trial in Intracerebral Hemorrhage

Background

The third INTEnsive care bundle with blood pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT3) is an ongoing, international, multicenter, stepped-wedge cluster, prospective, randomized, open, blinded endpoint assessed trial evaluating the effectiveness of a quality improvement “care bundle” for the management of patients with acute spontaneous intracerebral hemorrhage (ICH) in low- and middle-income countries (LMICs). An embedded process evaluation aims to explore the uptake and implementation of the intervention, and understand the context and stakeholder perspectives, for interpreting the trial outcomes.

Methodology

The design was informed by Normalization Process Theory and the UK Medical Research Council process evaluation guidance. Mixed methods are used to evaluate the implementation outcomes of fidelity, reach, dose, acceptability, appropriateness, adoption, sustainability, and relevant contextual factors and mechanisms affecting delivery of the care bundle. Semi-structured interviews and non-participant observations are conducted with the primary implementers (physicians and nurses) and patients/carers to explore how the care bundle was integrated into routine care. Focus group discussions are conducted with investigators and project operational staff to understand challenges and possible solutions in the organization of the trial. Data from observational records, surveys, routine monitoring data, field notes and case report forms, inform contextual factors, and adoption of the intervention. Purposive sampling of sites according to pre-specified criteria is used to achieve sample representativeness.

Discussion

Implementation outcomes, and relevant barriers and facilitators to integrating the care bundle into routine practice, will be reported after completion of the process evaluation. The embedded process evaluation will aid understanding of the causal mechanisms between care bundle elements and clinical outcomes within complex health systems across diverse LMIC settings.

Trial Registration

The INTERACT3 study is registered at ClinicalTrials.gov (NCT03209258).

Carers using assistive technology in dementia care at home: a mixed methods study

Introduction

Informal carers support persons with dementia to live at home, even with deteriorating physical, social and cognitive issues. This study aims to examine the experiences and impact of Assistive Technology (AT) on carers, providing care for a person with dementia.

Methods

This is an explanatory sequential mixed methods study. The quantitative phase was an online and postal survey using the Carers Assistive Technology Experience Questionnaire and Short Form-12 (SF-12) questionnaire, with carers of persons with dementia in the UK, who used AT. The qualitative phase involved in-depth telephone interviews with a purposive sample of survey respondents and was analysed using hermeneutic phenomenology to develop, compare and explain the findings of the survey.

Results

The survey included data from 201 carers. Smartphones (45.5%) and tablet computers (45.0%) were the most frequently used AT. Multiple AT were used in the care of persons with dementia predominantly for safety (78.5%), communication (66.0%), and reminders (62.5%). The SF-12 indicated that carers in the 46–65 age group and carers who were not extremely satisfied with AT had lower mental component scores whilst carers who lived with the person with dementia and older carers had lower physical component scores. Twenty-three carers participated in the interviews, and 5 themes with 14 sub-themes were identified. The interviews helped confirm data from the survey on the impact of AT on the physical, mental and social wellbeing of the carers. It helped describe reasons for satisfaction with AT; how AT was used in daily life and strengthened caring relationships and how wider support systems enhanced the care of a person with dementia using AT.

Conclusions

This study describes the use of AT in the real-world context. AT supplements the care provided to people with dementia in the community. Appropriate use, access to AT and abilities of the carer can enhance the support provided through AT to both carers and the person with dementia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03167-4.

The working conditions for personal support workers in the Greater Toronto Area during the COVID-19 pandemic: a mixed-methods study

OBJECTIVE

During the height of the COVID-19 pandemic, personal support workers (PSWs) were heralded as healthcare 'heroes' as many of them cared for high-risk, vulnerable older populations, and worked in long-term care, which experienced a high number of COVID-19 outbreaks and deaths. While essential to the healthcare workforce, there is little understanding of PSW working conditions during the pandemic. The aim of our study was to examine the working conditions (including job security, work policies, and personal experiences) for PSWs in the Greater Toronto Area during the COVID-19 pandemic from the perspectives of PSWs.

METHODS

This study used a mixed-methods design. From June to December 2020, we conducted a survey of 634 PSWs to understand their working conditions during the COVID-19 pandemic. Semi-structured interviews with 31 survey respondents were conducted from February to May 2021 to understand in greater depth how working conditions were impacting the well-being of PSWs.

RESULTS

We found PSWs faced a range of challenges related to COVID-19, including anxiety about contracting COVID-19, reduced work hours, taking leaves of absences, concerns about job security, and losing childcare. While the COVID-19 pandemic highlighted the PSW workforce and their importance to the healthcare system (especially in the long-term care system), pre-existing poor work conditions of insecure jobs with no paid sick days and benefits exacerbated COVID-19-related challenges. Despite these hardships, PSWs were able to rely on their mental resilience and passion for their profession to cope with challenges.

CONCLUSION

Significant changes need to be made to improve PSW working conditions. Better compensation, increased job security, decreased workload burden, and mental health supports are needed.

Use of simulation to improve nursing students' medication administration competence: a mixed-method study

Background

Medication administration errors are among the most important adverse events in healthcare systems. To minimise the risk of this occurring, nursing training programmes should emphasise the overriding priority of patient safety. In this respect, simulation can be a valuable resource in teaching procedures, for patient safety in general and safe medication administration in particular. In this study, we evaluate the use of a simulation-based activity for students to acquire skills in safe medication administration, and consider the students’ perceptions of this activity.

Methods

Second-year nursing students enrolled in the subject of pharmacology at a Spanish university during the academic year 2018–2019 were invited to participate in this mixed-method study. Their acquisition of professional competencies via a simulation exercise was evaluated according to the ‘six rights’. Before the simulation, each student completed a researcher-developed online questionnaire. The simulation was evaluated by the students’ tutor, using a checklist. A descriptive analysis was made of the data obtained from the questionnaire and during the simulation. At the end of the semester, the students' opinions were recorded in the questionnaire, in response to an open question. A content analysis was made of the responses to the open question.

Results

The simulation exercise was performed by 179 students, of whom 73 had previously completed the questionnaire. Analysis showed that, in comparison with the pre-simulation questionnaire results, compliance with the six rights improved in all dimensions except data documentation: right patient (from 64.4% to 83.3%); right medication (from 60.3% to 95.8%); right dose (from 60.3% to 100%); right route (from 54.8% to 95.8%); right time (from 24.7% to 70.8%); the right documentation result fell from 54.8% to 45.8%. The students expressed their satisfaction with the simulation method, affirming that it brought them closer to the reality of health care.

Conclusions

Simulation is a useful tool for the acquisition of skills in medication administration. The students were satisfied with the simulation capacity to bridge the gap between theory and practice. Moreover, simulation represents an added teaching resource in the nursing degree curriculum and is expected to enhance patient safety.

Protocol for READY2Exit: a patient-oriented, mixed methods study examining transition readiness in adolescents with co-occurring physical and mental health conditions

Background

Up to 57% of adolescents and young adults (AYA) with chronic physical health conditions experience mental health conditions, the presence of which contributes to increased morbidity and poor quality of life. AYA with co-occurring physical and mental health conditions, therefore, may experience additional challenges as they transition from pediatric to adult services. While transition readiness – the acquisition of self-management and advocacy skills – contributes to successful transitions to adult care, this concept has not been adequately explored for AYA with co-occurring physical and mental health conditions. Research is needed to identify whether the presence of a mental health comorbidity is associated with transition readiness, and what the experiences of AYA with co-occurring conditions are as they exit pediatric services. This paper outlines the protocol for the Readiness and Experiences of ADolescents and Young Adults with Co-occurring Physical and Mental Health Conditions Exiting Pediatric Services (READY2Exit) study; the first study to address this gap using a patient-oriented, mixed methods design.

Methods

A sequential explanatory mixed methods design will be used to understand the transition readiness of 16–21 year olds with physical and mental health conditions using quantitative and qualitative data. First, Transition Readiness Assessment Questionnaire (TRAQ) scores will be compared among AYA with chronic health conditions, with and without mental health comorbidity. Interviews will then be conducted with approximately 15 AYA with co-occurring health and mental health conditions and analyzed using qualitative description. The READY2Exit study will be conducted in collaboration with five Young Adult Research Partners (YARP) aged 18–30 with lived experience in the health/mental health systems across Canada. The YARP will partner in key tasks such as interview guide co-design, data interpretation, and knowledge translation tool development.

Discussion

AYA with co-occurring physical and mental health conditions may have unique needs as they prepare for health care transitions. The results of this study will inform the refinement of transition readiness practices to improve care for this group. The active involvement of the YARP across study phases will bring the critical perspectives of young adults to READY2Exit, ensuring the methods, research approaches and outputs align with their needs.

Tele-Balint under the microscope: What really happens in Tele-Balint groups?

OBJECTIVE

Balint groups provide a safe space for clinicians to discuss difficult cases, with the aim of deepening the clinician-patient relationship and providing space for self-introspection and personal development. During this COVID-19 period, mental health clinicians need a platform to undergo professional supervision and peer learning sessions, which can be provided for by Tele-Balint sessions. This study aims to understand the workings of Balint groups in a multi-disciplinary team, through exploring the experience and perceptions of mental health clinicians in a tertiary obstetrics- and paediatrics-focused hospital in Singapore towards Tele-Balint groups, and examining if these groups can address their professional needs.

METHOD

A mixed-methods study was conducted. 26 mental health clinicians who had participated in Tele-Balint groups since March 2020 completed a semi-structured questionnaire, and 12 of them were interviewed. Qualitative analysis of interview transcripts was performed.

RESULTS

Qualitative analysis revealed 5 themes. The first 4: professional and personal growth of clinicians, providing emotional support to clinicians, burnout in clinicians: what contributes and what helps, and psychological safety, address whether Tele-Balint groups meet clinicians' needs. The last theme, evolution of nature of Balint groups, addresses whether Tele-Balint groups meet clinicians' needs during the time of a pandemic.

CONCLUSIONS

Tele-Balint group participation was found to be beneficial in facilitating personal and professional growth, providing emotional support and preventing burnout, despite some limitations. Members should maintain flexibility towards the Balint process, in order to accommodate others who have differing needs, especially in a multi-disciplinary group.

Language-in-Education Policy of Kazakhstan: Post-Pandemic Technology Enhances Language Learning

In the current times of rapid technological progress, the development of quality education and encouragement of educated youth are extremely important. For this reason, a number of state projects and programs were developed in the education system of modern Kazakhstan. This paper is devoted to the problems of multilingual education and emergency remote learning in this country. The primary objectives were to examine the language competence and preferences of undergraduates and to explore the impact of the COVID-19 pandemic on remote language learning. Here, we present the survey and interview results of non-linguistic specialty students regarding their language preferences in various spheres, as well as the difficulties encountered during distance learning.

Broadening the scope of social support, coping skills and resilience among caretakers of children with disabilities in Uganda: a sequential explanatory mixed-methods study

BACKGROUND

Most caretakers of children with disabilities (CWDs) have adverse health outcomes. Approximately 31% of the caretakers have clinical depression in the world. In Sub-Saharan Africa, 42% of them face severe psychological distress. Caretakers in Africa face additional cultural challenges that undermine their coping skills, access to social support, and resilience.

METHODS

This study used sequential explanatory mixed methods to examine the relationships of social support, coping skills and resilience among caretakers of CWDs in Uganda. A total of 621 caretakers were surveyed, and 43 of them participated in interviews. Hierarchical cluster analysis and binary logistic regression were conducted to determine coping patterns and predict caretakers' likelihood of using them. Hierarchical linear regression and thematic analyses then explored the relationships and perceptions of coping skills and resilience related to social support. A joint display was used to integrate results and show the convergence and expansion of quantitative and qualitative results.

RESULTS

Quantitative and qualitative findings converged that caretakers who received social support used adaptive coping skills and had higher resilience. Qualitative results expanded the finding that caretakers who received formal social support perceived it as a safer mode of care than informal social support.

CONCLUSIONS

The study expanded the scope of social support, coping skills, and resilience. Caretakers perceived formal social support from schools as a safe mode of care that enabled them to use adaptive coping skills and have high resilience. Therefore, enrolling children with disabilities in schools at an early age is beneficial for building the resilience of their caretakers.

The Effect of Integrating Service-Learning and Learning Portfolio Construction into the Curriculum of Gerontological Nursing

Background: With the rapid increase in the aging population, a greater number of older individuals will require nursing care in the future. Therefore, it is important for nurses to be willing to engage in gerontological nursing. Nursing students must increase their experience in providing care to older people during their education and must receive education that improves their attitudes toward aging; this will help provide care to the older people, develop positive attitudes toward aging, and increase their empathy and willingness to provide care to older people after graduation. Hence, studies focused on improving the attitude of nursing students toward aging are urgently required. Methods: In this mixed-method experimental study, participants were interviewed individually and observed to better understand the connection between quantitative and qualitative data. Service learning and learning portfolio constructions were integrated in the gerontological nursing curriculum of an experimental group, whereas traditional gerontological nursing curriculum was provided to a control group. Quantitative data on the nursing students were collected using the attitudes toward aging scale (ATAS) and older people behavioral intention scale (OBIS) and analyzed using descriptive and inferential statistics. Result: From the pre- to the post-test, the average ATAS and OBIS scores of the experimental group increased significantly, reaching a statistically significant level. However, the results of the control group indicated that the educational intervention does affect the attitudes toward aging and older people behaviors. A qualitative analysis revealed that educational intervention can improve the students’ attitudes toward aging and older people behavioral intention. Conclusion: Our study results showed that integrating community older people service and learning portfolio construction into the curriculum can effectively improve the attitudes of nursing students toward aging and older people’s behaviors, thus providing substantial assistance to students intending to care for the older people in the future.

Research on Design of Emergency Science Popularization Information Visualization for Public Health Events-Taking “COVID-19”as an Example

This study explores the optimization method of emergency popular science information design elements in public health events, breaks through the traditional design with the designer as the subjective consciousness and proposes an emergency popular science information design method oriented by perceptual narrative. First, relevant research on public health events was carried out to screen out and analyze relevant narrative information elements and image elements, and narrative element divergence tree was established to show evaluation indicators. Second, relevant personnel were invited to evaluate the importance and kansei engineering, factor analysis and other methods were used to establish the correlation evaluation indicators of narrative elements. Finally, the optimization narrative elements of popular science information design were calculated with the fuzzy evaluation method to provide an effective auxiliary role for the visualization design of emergency popular science information. Taking “COVID-19 Event” as an example, the narrative design practice of emergency popular science elements was carried out. According to 313 effective questionnaires, the satisfaction of “COVID-19 event” popular science information elements that adopt the optimization method is relatively high, which verifies the feasibility of this method. The conclusion proves that the perceptual narrative design method can obtain the perceptual identity from the audience and plays a positive role in disseminating emergency popular science information.

Inclusive Design of Workspaces: Mixed Methods Approach to Understanding Users

Accessible design within the built environment has often focused on mobility conditions and has recently widened to include mental health. Additionally, as one in seven are neurodivergent (including conditions such as ADHD, autism, dyslexia, and dyspraxia), this highlights a growing need for designing for ‘non-visible’ conditions in addition to mobility. Emphasised by the growing disability pay gap and the disability perception gap, people with disabilities are still facing discrimination and physical barriers within the workplace. This research aimed to identify key ways of reducing physical barriers faced by people with a disability and thus encourage more comfortable and productive use of workspaces for all. Once the need for designing for a spectrum of users and inclusive workspace design was understood, a survey was then circulated to students and staff at a large university in the UK (working remotely from home), with the aim of understanding how people have adapted their home spaces and what barriers they continue to face. Quantitative and qualitative results were compared to the literature read with key issues emerging, such as separating work and rest from spaces in bedrooms. The survey findings and literature were evaluated, extracting key performance-based goals (e.g., productivity and focus within a study space) and prescriptive design features (e.g., lighting, furniture, and thermal comfort), whilst also considering the inclusivity of these features. The key conclusion establishes that, to achieve maximum benefit, it is important to work with the users to understand specific needs and identify creative and inclusive solutions.

The impact of the COVID-19 pandemic on illicit drug supply, drug-related behaviour of people who use drugs and provision of drug related services in Georgia: results of a mixed methods prospective cohort study

Background

This study examines the effects of COVID-19 related restrictions on the supply of illicit drugs, drug-use behaviour among people who use drugs (PWUD) regularly (at least weekly), and drug-related service provision in Tbilisi, Georgia.

Methodology

In this mixed methods study, a cohort of 50 Georgian PWUD recruited through a snow-ball sampling participated in a bi-weekly online survey in April–September, 2020. They also took part in the qualitative telephone interviews at 12- and 24-week follow-up time points. In addition, four key informants (field experts) were interviewed monthly to assess their perceptions of changes in the illicit drug market and drug service delivery.

Results

Mean age in the sample was 36 (range 18–60); 39 (78%) were males. Perceived availability of drugs was reduced during the lockdown, and many PWUD switched to alternative substances when preferred drugs were not available. On average, participants used significantly fewer substances over the course of the study, from 3.5 substances in the preceding 14 days to 2.1 (aOR 0.92; 95% CI 0.90–0.94). Consumption of cannabis products declined significantly (aOR 0.89; 95% CI 0.84–0.95), likewise alcohol (aOR 0.94; 95% CI 0.88–1.0), diverted medicinal methadone (aOR 0.85; 95% CI 0.8–0.9) and diverted medicinal buprenorphine (aOR 0.91; 95% CI 0.84–0.99). PWUD cited fewer contacts with drug dealers, the lack of transportation, and the lack of conventional recreational environment as the main reasons for these changes. When access to sterile injection equipment was limited, PWUD exercised risk-containing injection behaviours, such as buying drugs in pre-filled syringes (aOR 0.88; 95% CI 0.80–0.96). Harm reduction and treatment programs managed to adopt flexible strategies to recover services that were affected during the initial stage of the pandemic.

Conclusions

COVID-19-related restrictive measures mediated specific changes in supply models and drug-use behaviours. While adjusting to the new environment, many PWUD would engage in activities that put them under increased risk of overdose and blood-borne infections. Harm reduction and treatment services need to develop and implement protocols for ensuring uninterrupted service delivery during lockdowns, in anticipation of the similar epidemics or other emergency situations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12954-022-00601-z.